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OPERATIVE    MIDWIFERY 


OPERATIVE      MIDWIFERY 


A  GUIDE  TO  THE  DIFFICULTIES  AND 
COMPLICATIONS   OF  MIDWIFERY   PRACTICE 


BY 

J.  M.  MUNRO  KERR,  M.D.,  CM.,  Glas. 

FELLOW  OF  THE  ROYAL  FACULTY  OF  PHYSICIANS  AND  SURGEONS,  GLASGOW 

PROFESSOR  OF  MIDWIFERV    AND  DISEASES    OF    WOMEN,    ANDERSON'S    COLLEGE    MEDICAL    SCHOOL 

OBSTETRIC  PHYSICIAN,  GLASGOW  MATERNITY  HOSPITAL  ;  GYNAECOLOGIST,  WESTERN  INFIRMARV  ; 

EXAMINER  IN   MIDWIFERY  AND  GYNAECOLOGY,  ST.  ANDREWS  UNIVERSITY;    PAST  PRESIDENT 

OF  THE  GLASGOW  OBSTETRICAL  AND  GYNAECOLOGICAL  SOCIETY  ;    LATE    ASSISTANT   TO  THE 

REGIUS  PROFESSOR  OF   MIDWIFERY,    GLASGOW   UNIVERSITY 


SECOND    EDITION 


WITH  299  ILLUSTRATIONS  IN  THE  TEXT 


NEW   YORK 
WILLIAM    WOOD    &    COMPANY 

MDCCCCXI 


TO   THE  MEMORY    OF 

ROBERT    BARNES,   M.D.,   F.R  C.P. 


PKEFACE  TO  THE  SECOND  EDITION 

Such  a  short  time  has  elapsed  since  the  First  Edition  was  published 
that  I  have  not  considered  it  necessary  to  make  many  important 
alterations  in  the  text.  The  slight  changes  and  additions  which  have 
been  made  are  in  the  chapters  on  Pubiotomy,  Cesarean  Section, 
Placenta  Praevia,  and  Rupture  of  the  Uterus. 

I  desire  to  take  this  opportunity  to  thank  those  who  reviewed  the 
work  when  it  first  appeared  for  their  kind  criticism.  Some  critics 
referred  to  errors  in  style ;  I  am  fully  conscious  of  many  such  errors, 
and  no  one  deplores  them  more  than  myself.  As  regards  a  certain 
discursiveness  referred  to  by  others,  I  feel  this  was  almost  unavoidable 
as  I  attempted  to  write  each  chapter  as  a  separate  article,  while  at 
the  same  time  trying  to  preserve  a  continuity  in  the  whole  work. 

My  best  thanks  are  tendered  to  Dr.  David  Shannon  for  much  help 

in  correcting  the  proofs  and  index. 

J.  M.  K. 

7,'  Claremont  Gardens,  Glasgow. 
June,  1911. 


PREFACE  TO  THE  FIRST  EDITION 


Many  years  have  elapsed  since  a  treatise  devoted  entirely  to  Operative 
Midwifery  has  appeared  in  the  English  language. 

In  venturing  to  consider  the  subject  in  these  pages,  I  have 
constantly  had  before  me  two  standard  works.  I  refer  to  Barnes' 
'  Lectures  on  Obstetric  Operations '  and  Herman's  '  Difficult  Labour,' 
the  former  a  classic  in  obstetric  literature,  the  latter  a  most  valuable 
companion  at  the  bedside. 

As  will  be  seen,  I  have  followed  very  much  the  same  lines  as 
Barnes,  whose  '  Lectures 1  have  always  appeared  to  me  nearly  perfect. 
Much,  however,  has  happened  since  the  publication  of  the  last  edition 
in  1886.  At  that  time  antisepsis  and  asepsis  in  midwifery  were  only 
beginning  to  be  discussed ;  abdominal  palpation  for  the  diagnosis  of 
presentations  and  positions  of  the  foetus  was  practised  by  only  a  few ; 
the  revival  of  symphysiotomy  had  newly  begun  ;  the  modern  operation 
of  Cesarean  section  had  been  described  by  Sanger  only  a  year  or  two 
previously ;  while  operations  upon  the  pregnant  or  parturient  woman 
for  abdominal  and  pelvic  tumours  were  had  recourse  to  only  in  the 
most  desperate  circumstances.  Indeed,  the  changes  that  have  taken 
place  have  their  parallel  only  in  the  revival  that  followed  the  scientific 
teaching  of  Ambroise  Pare. 

In  considering  the  various  pathological  conditions  causing  dystocia 
and  the  methods  of  dealing  with  them,  I  have  tried,  as  far  as  possible, 
to  indicate  what  is  becoming  more  apparent  eveiy  day,  that  the  art 
of  midwifery  can  no  longer  be  considered  a  subdivision  of  medicine, 
but  must  be  regarded  as  a  branch  of  surgery  requiring  a  thorough 
knowledge  of  surgical  principles. 

I  trust  it  shall  be  found  that  due  credit  has  been  given  to  those 
who  have  specially  advanced  the  art  of  obstetrics  in  recent  years. 
The  names  of  many  who  have  thus  distinguished  themselves  in  this 
and  other  countries  are  mentioned  throughout  the  text,  bat  it  is  im- 
possible to  avoid  overlooking  some,  and  to  them  I  offer  my  apologies. 


x  PREFACE 

For  actual  assistance  rendered,  I  desire  to  thank  especially  Dr.  •).  W. 
Ballantyne,  of  Edinburgh,  for  kindly  contributing  the  chapter  on 
dystocia  caused  by  doable  monsters;  J>r.  Kiddell,  of  the  Glasgow 
Royal  Infirmary,  for  his  note  on  pelvic  radiography;  and  Dr.  Dickie. 
my  assistant  at  the  Western  Infirmary,  for  revising  and  correcting  the 
proofs  and  rendering  me  much  assistance  in  other  ways.  1  am  also 
indebted  to  my  colleagues,  Drs.  Jardine  and  Russell  ;  Dr.  W.  L.  Beid, 
Dr.  Teacher,  Dr.  Lindsay.  Dr.  Dunlop,  and  Dr.  -lames  Scott,  of 
Glasgow  ;  Dr.  Adam  of  Hamilton,  Dr.  Hewetson  of  Birmingham,  Dr. 
Lloyd  Roberts  and  Dr.  Donald  of  Manchester,  1  )r.  Haultain  of  Edin- 
burgh ;  Dr.  Cullingworth,  Dr.  Herman,  Dr.  Spencer,  and  Mr.  Bland- 
Sutton,  of  London  ;  Professors  Bumm  and  Nagel  of  Berlin,  Professor 
Barr  of  Paris,  and  Professor  Edgar  of  Philadelphia,  for  permitting  me 
to  use  illustrations  and  statements  which  have  appeared  in  their 
published  works.  I  must  also  thank  the  publishers  of  the  Journal  <>' 
Obstetrics  and  Gynaecology  of  the  British  Empire,  the  Practitioner,  and 
the  American  Year-Book,  for  the  loan  of  several  valuable  illustrations, 
and  Messrs.  Arnold  and  Sons,  and  Gardner  and  Son,  for  the  blocks 
of  the  instruments  here  illustrated. 

Such  of  the  illustrations  of  the  pathological  specimens  as  have  not 
been  lent  me  are,  for  the  most  part,  from  photographs  and  drawings 
of  specimens  in  the  Hunterian  Museum,  Glasgow  University,  in  the 
Pathological  Institute  of  the  Western  Infirmary,  and  in  my  own 
collection.  The  photographs  of  the  different  stages  in  the  various 
operations  were  taken  under  my  direction  in  the  Glasgow  Maternity 
Hospital.  All  the  original  drawings  are  by  Mr.  A.  K.  Maxwell,  of 
Glasgow,  to  whom  I  am  grateful  for  the  trouble  he  has  taken. 

I  must  also  thank  the  publishers  for  the  courtesy  with  which  at  all 
times  they  have  met  my  wishes. 

J.  M.  MUNRO  KERB. 

7,  Claremont  Gardens,  Glasgow, 
August,  1908. 


CONTENTS 

CHAPTER  PAGE 

I.    CONSIDERATION    OF    DYSTOCIA    IN    GENERAL CLASSIFICATION'    OF 

DYSTOCIA  ..---.  1 

II.    DYSTOCIA      THE     RESULT     OF     FAULTS     IN     THE      FORCES  :      UNDUE 
STRENGTH    OF    THE    FORCES PRECIPITATE    LABOUR INEFFI- 
CIENCY'   OF    THE    FORCES      -                    -                    -                    -  -5 
III.    DYSTOCIA    THE     RESULT    OF    FAULTS    IN    THE    F(ETUS  :     ATTITUDE, 

POSITION,     AND     PRESENTATION ABDOMINAL     PALPATION 

VAGINAL     EXAMINATION AUSCULTATION OTHER     METHODS 

OF    EXAMINATION  -  -  -  -  -15 

IV.    DYSTOCIA    THE    RESULT    OF    FAULTS    IN    THE    FOETUS    {continued)  \ 

ABNORMAL  ATTITUDE  AND  POSITION  OF  THE  HEAD PROLAPSE 

OF    LIMBS    ASSOCIATED   WITH    PRESENTATIONS    OF    THE    HEAD    -  26 

V.    DYSTOCIA    THE    RESULT    OF    FAULTS    IN    THE    FOETUS    {continued)  \ 

BREECH    PRESENTATIONS     -  -  -  -  -  50 

VI.    DYSTOCIA  THE   RESULT  OF  ABNORMALITIES  AFFECTING  THE    FOETUS 

{continued)  :   transverse  or  oblique  presentations        -       86 

VII.    DYSTOCIA  THE   RESULT  OF  ABNORMALITIES  AFFECTING   THE  FOETUS 

{continued) :    malformation  of  the  foetus  -  -        97 

VIII.    DYSTOCIA  the  result  of  ABNORMALITIES  affecting  THE  FOETUS 

{continued):   presence  of  more  than  one  foetus  -     113 

IX.  dystocia  the  result  of  abnormalities  affecting  the  foetus 

{continued)  :    double  monsters    -  122 

X.  dystocia  the  result  of  abnormalities  affecting  the  foetus 

{continued):   cord — placenta — membranes  -  -      132 

XI.  DYSTOCIA  THE   RESULT  of  abnormalities  affecting  the  par- 

turient    CANAL  :      DEFORMITIES     OF     THE     BONY     CANAL  

CLASSIFICATION    OF   THESE    DEFORMITIES    AND   CONSIDERATION 

OF    THE    DIFFERENT    VARIETIES  -  153 


xii  CONTENTS 

OHAl  PAI  I 

Mi.  DYSTOCIA  nil.  RESULT  OF  ABNORMALITIES  AFFECTING  THI 
PARTURIENT  CANAL  (continued):  DIAGNOSIS,  PROGNOSIS, 
AND  TREATMENT  01  PELVK  DEFORMITY,  MORE  ESPECIALLY 
OF   THE    RACHITIC    VARIETIES    OF    MALFORMATION  -       177 

Mil.  DYSTOCIA  THE  RESULT  OF  ABNORMALITIES  AFFECTING  THE 
PARTURIENT  (ANA  I.    (continued):    ABNORMALITIES    IS   tin 

son   parts:    cervix — vagina — perineum  -  -     201 

XIV.    DYSTOCIA     THE    RESULT    OF    ABNORMALITIES    AFFECTING    THE 
PARTURIENT     CANAL     (continued)  :     CARCINOMA     OF     THE 
CERVIX  -  -  -  -  -  -       214 

W.    DYSTOCIA    THE     RESULT    OF    ABNORMALITIES    AFFECTING    'I'M  I 

PARTURIENT  (ANAL  (continued):    TUMOl  Its  OF  THE  OVARY       222 

XVI.    DYSTOCIA    THE     RESULT    OF    ABNORMALITIES    AFFECTING    THE 
PARTURIENT    CANAL    (continued )  :     FIBRO-MYOMA    OF    THE 
UTERUS  .-...-      235 

XVII.    DYSTOCIA    THE     RESULT    OF    ABNORMALITIES    AFFECTING     THE 
PARTURIENT  CANAL  (continued):  TUMOURS  OF  THE  BLADDEH 
AND    RECTUM     ------       256 

XViii.  DYSTOCIA  THE  RESULT  OF  ABNORMALITIES  AFFECTING  THE 
PARTURIENT  CANAL  (continued)  :  SUPPURATIVE  CONDITIONS 
IX    PELVIS    AND    ABDOMEN  ....       2(i() 

MX.  DYSTOCIA  THE  RESULT  OF  ABNORMALITIES  AFFECTING  THE 
PARTURIENT  <  A\.\u(continued):  ALTERATIONS  IX  THE  AXIS 
OK  THE  CANAL — DISPLACEMENTS  BACKWARD,  FORWARD, 
AND  DOWNWARD — DISPLACEMENTS  THE  RESULT  OF  VAGINAL 
AND    ABDOMINAL    FIXATION    OF   THE    UTERUS  -  -       2ti" 

XX.  DYSTOCIA    THE     RESULT    OF    ABNORMALITIES     AFFECTING     THE 

PARTURIENT     CANAL     (continued)  :      MALFORMATIONS     OF 

THE    UTERUS    AND    VAGINA  ...  -       2!»4 

XXI.  PREPARATIONS  FOR  OPERATION — PREPARATION  OF  OPERATING- 

ROOM —  INSTRUMENTS  AND  APPLIANCES — OPERATOR*^  HANDS 
— PATIENT — ANAESTHESIA  ....       303 

XXII.    VERSION,    on    TURNING         -----       316 

xxin.  forceps-  ._....     :;:!:; 

xxiv.    FORCEPS    (continued ):    FORCEPS    IX    CONTRACTED    PELVIS          -  363 
XXV.    THE     ENLARGEMENT     OF    THE     PELVIC     CAPACITY  — SYMPHY- 
SIOTOMY   AND    HEBOSTEOTOMY    (pUBIOTOMy)              -                  -  374 
XXVI.    CESAREAN    SECTION               -----  404 


CONTENTS  xiii 

CHAPTER  l'AOE 

XXVII.    [NDUCTION    OF    PREMATURE    LABOUR  ...       435 

XXVIII.    ACCOUCHEMENT       FORCE,      INCLUDING       VAGINAL       CESAREAN 

SECTION  •  -  -  -  -  -      456 

XXIX.     OPERATIONS       INVOLVING        DESTRUCTION       OF       THE       CHILD   : 

CRANIOTOMY  DECAPITATION  EVISCERATION CLEID- 

OTOMY  --.-.-      478 

XXX.     MANUAL    REMOVAL    OE    PLACENTA    AND    MEMBRANES  -       508 

XXXI.    INTERRUPTED     GESTATION ABORTION     AND     HYDATIDIFORM 

MOLE  -------       517 

XXXII.    ECTOPIC    PREGNANCY PELVIC    HEMATOCELE — PREGNANCY   IN 

RUDIMENTARY    HORN    (CORNUAL    PREGNANCY)  -  -        537 

XXXIII.    PLACENTA    PREVIA — •ACCIDENTAL    HEMORRHAGE  -  -       577 

XXXIV.     POST-PARTUM    HEMORRHAGE  -  -  -        607 

XXXV.    ACCIDENTS    TO    MOTHERS  :     LACERATION    OF    UTERUS,    VAGINA, 

PERINEUM,    SYMPHYSIS    PUBIS         -  -  -  -       616 

XXXVI.    ACCIDENTS  TO  MOTHERS  (conti)lUed)  :   INVERSION  OF  UTERUS 

PULMONARY    EMBOLISM SUBCUTANEOUS    EMPHYSEMA  -       655 

XXXVII.    ACCIDENTS       TO       CHILD  :       INJURIES       TO       BONES,      MUSCLES, 

NERVES,    VISCERA,    ETC.  ;    ASPHYXIA    NEONATORUM  -        Q66 

APPENDIX  -  -  -  687 

INDEX       -------       690 


OPERATIVE    MIDWIFERY 


CHAPTER  I 

CONSIDERATION  OF  DYSTOCIA  IN   GENERAL- CLASSIFICATION 

OF  DYSTOCIA 

When  all  the  most  distinguished  writers  of  obstetric  treatises  in  the 
past  have  failed  to  give  an  absolutely  satisfactory  definition  of  dystocia, 
it  may  be  fairly  assumed  that  the  task  is  impossible.  That  this  should 
be  so  is  not  to  be  wondered  at  when  the  other  condition  of  normal 
labour  or  eutocia  can  only  be  described  by  cumbersome  details  of  its 
phenomena.  Fortunately,  a  definition  is  not  essential  to  an  under- 
standing of  dystocia.  One  is  not  long  in  obstetric  practice  until  one 
forms  an  idea  of  the  condition ;  indeed,  it  might  prevent  a  full  appre- 
ciation of  the  fact  that  Nature  in  parturition,  although  generally 
following  a  certain  course,  refuses  to  be  trammelled  by  hard-and-fast 
rules.  It  is  important  for  the  accoucheur  to  remember  this,  and  to 
appreciate  within  what  limits  she  may  be  allowed  a  free  hand.  The 
mistake  is  too  often  made  of  forgetting  this  and  of  interfering  with 
Nature,  when,  with  a  little  patience,  it  would  have  been  unnecessary. 

But  if  it  is  of  great  importance  that  the  accoucheur  should 
appreciate  the  natural  variations  of  parturition,  it  is  equally  im- 
portant that  he  should  recognize  when  Nature  is  at  fault  and  requires 
assistance,  and  that  he  should  do  this  as  early  as  possible.  He  must 
never  presume  that  a  parturition  is  normal.  He  must  not  be  content 
until  he  has  satisfied  himself  that  it  is  not  abnormal.  This  attitude  must 
be  assumed  in  every  labour.  Again  and  again  one  sees  how  failure  to 
do  this  results  in  complications  being  overlooked  until  they  cannot  be 
remedied,  and  the  child's,  and  even,  occasionally,  the  mother's,  life  is 
sacrificed  or  greatly  endangered. 

Another  matter  which  the  accoucheur  should  ever  bear  in  mind 
is  the  limitations  of  the  different  operative  procedures.  Repeatedly 
in  the   last   few  years  cases   have   been   admitted   to   the   Glasgow 

l 


2  OPEBATIVE  M1DW  IFKKY 

Maternity  Hospital  where  the  medical  attendant  has  failed  absolutely 
to  appreciate  this.  Most  of  these  cases  have  been  examples  of  con- 
tracted pelvis  or  impacted  shoulder  presentation.  It  would  appear  as 
if  the  accoucheur  considered  it  a  disgrace  not  to  be  able  to  accompli sfa 
delivery  by  forceps  or  by  version,  and  so  he  has  recourse  to  unjustifiable 
force.  As  I  shall  point  out  in  the  following  pages,  the  employment 
of  extreme  force  is  always  wrong ;  it  may  often  be  followed  by  no 
trouble — indeed,  it  may  even  appear  to  be  quite  successful — but  in 
hundreds  of  cases  it  results  in  more  or  less  serious  consequences,  and 
it  is  absolutely  unscientific.  It  almost  invariably  means  that  the 
operation  is  unsuitable  or  is  being  badly  performed.  I  cannot  deny 
that  occasionally  one  is  compelled  to  exert  considerable  force  in 
exceptional  circumstances.  These  circumstances,  however,  will  be 
referred  to  in  their  proper  places.  Here  I  would  only  remark  that 
when  an  undue  amount  of  force  is  employed  in  the  extraction  of  the 
child  it  should  only  be  exerted  in  the  interests  of  the  child.  If  the 
child  is  dead  or  dying,  delivery  should  be  completed  by  diminishing 
the  bulk  of  the  child  by  embryulcia.  It  is  quite  profitless  to  drag 
a  dead  child  out  of  the  parturient  canal  with  difficulty,  when  by 
performing  craniotomy  one  could  extract  it  with  great  ease.  In  a 
difficult  labour,  therefore,  the  accoucheur  must  carefully  observe  the 
condition  of  the  child.  He  must  never  sacrifice  it,  if,  with  safety  to  the 
mother,  he  can  save  it,  but  he  must  effect  the  delivery  in  the  easiest 
manner  should  it  succumb. 

Naturally,  the  relative  claims  of  mother  and  child  frequently 
require  to  be  considered  in  cases  of  dystocia,  and  nothing  taxes  so 
much  the  judgment  of  the  accoucheur  as  giving  each  its  proper  place, 
for  their  interests  are  often  antagonistic.  Let  me  illustrate  this  by 
two  simple  examples.  In  placenta  praevia  by  rapidly  dilating  the 
cervix  and  extracting  the  child  a  large  proportion  of  children  will  be 
saved,  but  by  doing  so  one  subjects  the  mother  to  very  great  danger ; 
on  the  other  hand,  by  bringing  down  a  foot,  one  does  the  safest  thing 
for  the  mother,  but  not  the  best  for  the  child.  Again,  take  a  case  of 
contracted  pelvis  where  labour  has  been  allowed  to  proceed  to  an 
advanced  stage  and  many  vaginal  examinations  have  been  made.  If 
the  child  is  still  alive,  Cesarean  section  will  almost  certainly  result  in 
its  life  being  saved,  but  the  danger  of  sepsis  to  the  mother  will  be 
enormous,  while  if  craniotomy  is  performed  the  child  will  be  sacrificed, 
but  the  mother  probably  rescued.  Only  experience  and  a  quiet  con- 
sideration of  all  the  circumstances  will  teach  the  obstetrician  how  to 
act.  No  hard-and-fast  rules  can  be  laid  down,  and  different  obstetri- 
cians, of  equal  ability,  knowledge,  and  experience,  may  act  differently 
under  the  same  circumstances.  The  obstetrician  must  ever  avoid  taking 


CLASSIFICATION  OF  DYSTOCIA  8 

up  an  extreme  position  and  becoming  a  partisan  for  or  against  any 
particular  treatment.  Progress  in  obstetrics  has  been  much  retarded 
in  all  ages  by  those  who  have  unfortunately  adopted  such  an  attitude. 
"When  one  finds  equally  distinguished  obstetricians  holding  absolutely 
different  views,  it  is  almost  certain  that  the  right  is  with  none. 
Personally,  I  know  of  no  recognized  obstetric  operation  which  has  not 
its  place  and  may  not  be  practised  with  advantage  under  certain 
conditions,  and  I  consider  that  obstetrics  has  been  greatly  advanced 
by  the  revival  of  symphysiotomy,  by  pubiotomy,  and  by  vagimd 
Cesarean  section. 

There  are  three  factors  which  influence  labour — the  forces,  the 
child,  and  the  passage — and  no  attitude  towards  dystocia  could  be 
sounder  than  attempting  to  estimate  in  every  case  how  far  each  of 
these  factors  is  disturbed.  This  is  often  difficult,  especially  in  the 
minor  forms  of  dystocia,  for  sometimes  more  than  one,  and  indeed  all 
three,  are  at  fault.  The  obstetrician,  however,  must  carefully  consider 
all,  and  relegate  to  each  its  proper  place.  The  easiest  explanation  of 
a  delay  or  difficulty  is  to  blame  the  forces — the  factor  which  is  most 
indefinite  and  most  difficult  to  exactly  estimate.  For  this  very  reason, 
therefore,  and  because  it  is  the  least  serious,  the  accoucheur  should 
not  rest  satisfied  with  attributing  the  trouble  to  it  until  he  has  made 
certain  that  neither  of  the  other  two  factors  is  disturbed.  This  matter 
will  be  more  fully  considered  in  the  next  chapter. 

But  labour  may  be  further  disturbed  by  accidents  to  the  parturient, 
such  as  rupture  of  the  uterus  ;  by  haemorrhage,  such  as  that  which 
is  associated  with  placenta  prsevia ;  by  displacements  of  the  uterus, 
such  as  retroversion,  all  of  which,  and  many  other  complications 
considered  in  these  pages,  the  accoucheur  must  be  alert  to  appre- 
ciate and  deal  with.  Frequently  he  has  to  do  this  with  all  celerity 
under  conditions  not  too  favourable  and  with  very  inadequate  assistance. 
Appreciating  this  fully,  I  have  tried,  in  considering  all  complications, 
not  only  to  describe  the  ideal  treatment  of  the  particular  condition,  but 
also,  when  such  a  treatment  is  impossible,  to  indicate  the  best  course 
to  follow  under  the  circumstances. 

There  remains,  however,  another  group  of  cases  where  the  factors 
of  labour  may  or  may  not  be  disturbed,  but  where  operative  interfer- 
ence becomes  necessary  in  the  interests  of  the  mother  or  child,  because 
the  vitality  of  mother  or  child  shows  signs  of  progressive  weakness. 

In  the  case  of  the  mother,  where  actual  disease  such  as  valvular 
disease  of  the  heart,  phthisis,  hyperemesis,  etc.,  are  not  present,  it  will 
be  found  almost  without  exception  that  one  or  more  of  the  factors  of 
labour  is  disturbed.  In  this  connexion  it  must  be  remembered  that 
women  bear  labour  very  differently,  and  that  consequently,  with  some 


4  OPERATIVE  MIDWIFERY 

it  is  necessary  to  interfere  earlier  than  with  others.  Generally  speak- 
ing, the  cardiac  condition,  as  indicated  by  the  pulse,  is  a  fair  guide. 
To  have  the  full  benefit  of  this  guide,  however,  one  must  know  before- 
hand the  ordinary  rate  and  character  of  the  pulse,  for  I  have  found 
it  by  no  means  uncommon  to  get  a  pulse-rate  of  1)0  or  100  quite  early 
in  labour — indeed,  even  during  the  later  weeks  of  pregnancy.  A 
steadily  rising  pulse-rate  is  of  most  value,  and  must  always  be  looked 
upon  as  a  danger-signal.  The  same  applies  to  a  steadily  rising 
temperature  and  increasing  restlessness. 

I  have  only  referred  to  the  early  indications  for  interference,  and 
have  not  mentioned  tetanic  contraction  of  the  uterus,  tenderness  over 
the  lower  uterine  segment,  and  the  appearance  of  Bandl's  ring. 
Without  doubt,  these  also  are  indications  for  immediate  delivery.  As 
we  shall  see,  when  rupture  of  the  uterus  is  being  considered,  they  are 
symptoms  of  the  very  greatest  seriousness.  But  they  should  never 
be  allowed  to  develop ;  the  uterus  should  be  emptied  long  before  they 
make  their  appearance. 

As  regards  the  child,  a  steady  slowing  of  the  fcetal  heart,  especially 
when  the  rate  decreases  to  about  100,  always  points  to  the  child's 
life  being  in  danger.  At  such  a  time  one  finds  the  cardiac  sounds  much 
affected  by  the  uterine  contractions.  At  all  times  they  are  very  much 
slower  during  the  contractions,  but  if  the  child's  vitality  is  undisturbed 
they  quickly  return  to  the  ordinary  rate  as  the  contractions  pass  off. 
When  they  return  slowly,  and  especially  when  they  are  irregular, 
there  is  no  time  to  lose  if  the  child  is  to  be  saved. 

The  escape  of  meconium  in  all  presentations  other  than  the  breech 
is  another  danger-signal  on  the  side  of  the  child.  No  doubt  small 
quantities  of  meconium  are  discharged  into  the  amnionic  cavity  even 
during  pregnancy,  but  its  free  escape  during  labour,  unless  the 
child's  cardiac  condition  is  absolutely  satisfactory,  calls  for  speedy 
delivery. 

Strong  and  irregular  foetal  movements  also  frequently  precede 
the  death  of  the  foetus  during  labour.  With  the  mother  very  restless 
and  suffering  from  the  pains  of  labour,  however,  such  a  symptom  is 
seldom  of  much  practical  value.  We  must  depend,  therefore,  almost 
entirely  upon  the  condition  of  the  foetal  heart.  If  the  labour  is  at  all 
protracted,  the  accoucheur  must  auscultate  the  foetal  heart  frequently ; 
he  must  note  its  rate  and  character,  and  how  it  is  affected  by  the 
uterine  contractions. 


CHAPTER  II 

DYSTOCIA  THE  RESULT  OF  FAULTS  IN  THE  FORCES 

Undue  Strength  of  the  Forces — Precipitate  Labour — Inefficiency 

of  the  Forces. 

If  the  question  were  asked,  What  is  the  commonest  cause  of  minor 
dystocia  and  delay  in  labour  ?  without  doubt  the  answer  would  be — 
Faults  in  the  expulsive  forces.  But,  while  such  an  answer  is  quite 
correct,  all  who  have  had  much  experience  of  obstetric  practice  must 
admit,  that  very  frequently  such  an  explanation  is  given  too  readily 
and  without  sufficient  consideration.  It  is  so  simple  and  vague  that 
one  is  tempted  to  be  satisfied  with  it,  whenever  the  cause  of  the 
dystocia  is  not  strikingly  apparent.  I  have  frequently  found  the 
real  cause  some  little  departure  from  the  normal  in  the  pelvic  cavity 
or  in  the  position  or  attitude  of  the  child,  so  much  so  that  I  think 
it  a  good  rule  to  attribute  delay  and  difficulty  in  labour  only  to  faults 
in  the  forces,  when  one  has  absolutely  satisfied  oneself  that  the  fault 
is  not  in  the  passage  or  passenger. 

In  approaching  this  subject  of  the  forces  as  a  factor  of  dystocia, 
one  is  arrested  at  the  very  outset,  by  the  fact  that  there  is  no  standard 
for,  or  means  of,  estimating  the  forces.  With  dystocia  associated  with 
the  passage  and  passenger,  we  shall  see  that  it  is  quite  otherwise,  for 
by  investigation  and  careful  consideration  the  degree  of  difficulty  may 
be  fairly  correctly  surmised. 

I  have  said  that  there  is  no  means  of  estimating  the  forces.  By 
that,  I  mean,  there  is  no  practical  method  of  doing  so  beyond  the 
simple  expedient  of  applying  a  hand  over  the  abdomen  and  estimating 
the  frequency,  duration,  and  effect  of  the  uterine  contractions.  One 
cannot  measure  the  forces,  and  say  that  one  has  a  force  of  so  many 
millimetres  of  mercury  too  little  or  too  much. 

There  have  been  many  attempts  to  measure  the  forces  of  labour. 
Duncan  and  Poppel,  for  example,  estimated  the  resistance  of  the 
membranes  to  a  bursting  force.  Others  attempted  to  measure  them 
by   attaching   a   dynamometer   to   the    forceps,    and    so    estimating 

5 


Fig.  L— Schatz's  Tokodynamomete 


PRECIPITATE  LABOUR  7 

the  amount  of  force  required  to  extract  the  child.  It  is,  however, 
unnecessary  to  discuss  results  obtained  by  such  methods,  for  it  is  at 
once  apparent  that  no  exactness  could  possibly  be  obtained  by  such 
devices. 

The  earliest  and  most  scientifically  constructed  instrument  for 
calculating  the  uterine  force  is  the  tokodynamometer  of  Schatz 
(Fig.  1),  described  some  forty  years  ago.1  By  means  of  it,  and  its 
modifications,  many  interesting  observations  and  tracings  have  been 
made  by  different  observers,  showing  the  features  of  normal  and 
abnormal  uterine  contractions.  In  recent  years  Schaffer2  has  given 
this  subject  special  consideration,  and  by  means  of  his  instrument  has 
also  made  many  tracings.  Schaffer's  instrument  (Fig.  2)  has  the 
advantage  of   being  more  easily  applied,  although,   of  course,   one 


Fig.  2.— Schaffer's  Pelotte. 

cannot  estimate  the  uterine  contractions  so  accurately  with  it,  as  with 
Schatz's  and  similar  instruments.  Schaffer  states  that  in  the  interval 
of  the  contractions  the  pressure  is  5  millimetres  of  mercury,  and 
during  the  contractions  it  varies  from  80  to  220  millimetres.  He  also 
considers  that  the  power  of  the  uterine  contractions  and  auxiliary 
forces  is  about  equal.  But  although  such  instruments  and  investiga- 
tions are  of  decided  scientific  interest  (Fig.  3),  they  are,  at  present,  of 
no  practical  value.  In  practice  one  can  only  estimate  the  efficiency 
of  the  forces  of  labour  by  the  progress  made. 

The  expulsive  forces  may  be  abnormal  in  three  ways :  they  may 
be  unusually  strong,  they  may  be  unusually  feeble  and  ineffective, 
and  they  may  be  irregular  (tetanic). 

Precipitate  Labour. — Although  excessively  strong  uterine  con- 
tractions and  the  resulting  condition  of  precipitate  labour  does  not, 
properly  speaking,  come  under  the  head  of  dystocia,  it  is  a  subject, 
regarding  which  it  is  permissible  to  say  a  word.  The  first  striking 
feature  of  precipitate  labour  as  one  encounters  it  in  practice,  is  the 

1  Archiv  f.  Gyn.,  Bds.  iii.  and  xxvii. 

2  '  Experimentelle  Untersuchungen  iiber  Wehenthiitigkcit,'  Berlin,  1896. 


8  OPERATIVE  MIIAYIKKHY 

fact  that  it  is  peculiar  to  certain  individuals.  This  is  due  not  only  to 
the  strength  of  the  uterine  contractions,  but  also,  and  even  in  greater 
part,  to  the  slight  resistance  offered  by  the  soft  parts  of  the  parturient 
canal.  Very  frequently  such  patients  state  that  they  have  had  only 
'  one  or  two  pains,'  which  shows  that  the  process  of  dilatation,  usually 
accompanied  by  much  suffering,  occasionally  does  not  set  up  nervous 
phenomena  termed  'pain.' 

The  ordinary  dangers  of  precipitate  labour  are  familiar  to  every 
one — rupture  of  the  perineum,  post-partum  haemorrhage,  injuries  to 
the  child.  In  addition,  there  has  occasionally  followed  a  subcutaneous 
emphysema,  and  still  more  rarely  fracture  of  the  sternum.  Both 
these  complications  are  considered  in  Chapter  XXXVI.  Walthard  ' 
points   out   that   emphysema    is   very   rare    in    precipitate    labour. 


Fig.   3. — Uterine  Contractions  registered  by  Schiifl'er's  Instrument. 

Certainly,  the  two  cases  I  have  had  experience  of  followed  labours 
in  which  the  bearing-down  efforts  were  prolonged  and  of  unusual 
severity. 

Uterine  Inertia. — We  are  more  concerned  here,  however,  with 
the  other  condition,  in  which  the  expulsive  forces  are  feeble  and 
ineffective.  As  the  expulsive  forces  consist  of  two  component  parts, 
the  uterine  contractions  and  the  auxiliary  forces,  it  is  natural  to 
expect  that  labour  may  be  protracted  sometimes  by  one,  sometimes 
by  the  other,  and  occasionally  by  both  being  at  fault. 

Uterine  contractions,  to  be  effective,  should  possess  three  character- 
istics. They  should  occur  at  regular  but  not  too  long  intervals,  they 
should  be  strong,  and  they  should  be  sustained.  As  labour  advances 
these  features  should  become  more  decided.  Sometimes  all  three  are 
at  fault,  but  the  most  frequent  cause  of  delay  is  the  weakening  and 
cessation  of  the  contractions  just  when  they  should  continue. 

Uterine  inertia  may  be  primary  or  secondary.  Primary  uterine 
inertia  is  due  to  inherent  weakness  of  the  uterine  muscle  or  to  errors 
1  Winckel's  '  Handbuch,'  1905,  Bd.  ii.,  Teil  iii.,  p.  2094. 


INEFFICIENCY  OF  THE  FORCES  9 

in  its  innervation.  It  may  also  be  the  result  of  some  reflex  irrita- 
tion inhibiting  the  action  of  the  muscular  contractions.  Secondary 
uterine  inertia,  on  the  other  hand,  results  from  the  muscle  becoming 
tired  and  worn  out.  Primary  uterine  inertia  ma}'  be  easy  of  explana- 
tion, as  in  cases  where  the  uterus  is  known  to  be  diseased  from 
chronic  metritis,  or  tumours  ;  is  overdistended  by  an  excessive 
quantity  of  liquor  amnii  or  more  than  one  fetus  ;  or  has  its  con- 
tractions inhibited  by  some  reflex  irritation,  such  as  retention  of 
urine,  premature  rupture  of  membranes,  etc.  In  very  many  cases  it 
is  extremely  difficult  to  account  for  the  inertia,  and  in  such  errors 
in  development  and  innervation  are  vaguely  spoken  about.  Although, 
however,  one  cannot  always  give  a  reason  for  the  inertia,  one  can  at 
least  say  that  it  is  not  necessarily  found  in  cases  of  general  debility. 
Nor  is  it  a  characteristic  of  individuals  of  feeble  muscular  develop- 
ment ;  indeed,  it  has  been  my  experience  to  find  it  more  commonly  in 
the  strong  and  athletic  than  in  those  of  poor  muscular  physique.  It 
is  often  a  feature  of  labour  in  young  primiparse,  and  is  not  infre- 
quently seen  in  old  primiparse.  In  the  cases  of  decided  uterine  mal- 
formation which  have  been  under  my  care  it  has  not  been  a  striking 
feature,  although  others  have  observed  it  in  such  cases. 

Secondary  uterine  inertia  is  quite  different.  Here,  one  has  to  deal 
with  forces  which  up  to  a  certain  point  were  acting  quite  satis- 
factorily, but  which  for  some  reason  gave  out.  If  there  has  been  a 
prolonged  labour,  and  especially  if  there  has  been  some  abnormality 
in  passage  or  foetus,  one  can  readily  understand  this,  for  muscle 
cannot  go  on  contracting  indefinitely,  it  becomes  exhausted.  The 
time  at  which  the  uterine  muscle  becomes  fatigued  varies  in  different 
individuals ;  sometimes  it  occurs  early,  sometimes  late.  Many  speak 
vaguely  of  defective  innervation  in  such  cases,  and  claim  that  this 
results  from  congestion  of  the  lower  part  of  the  uterus  and  cervix. 
Certainly  it  is  not  uncommon  in  cases  of  premature  rupture  of  the 
membranes,  and  "  generally  contracted  "  pelves,  in  both  of  which  the 
presenting  head  presses  unduly  on  the  lower  part  of  the  uterus. 

In  the  second  stage  of  labour,  when  the  expulsive  forces  are  feeble, 
the  uterus  is  often  blamed,  when,  as  a  matter  of  fact,  the  fault  is  more 
in  the  auxiliary  forces.  One  repeatedly  sees  regular,  strong,  and  even 
frequent  uterine  contractions  cease  when  they  should  continue.  In 
such  cases  it  will  invariably  be  found  that  the  auxiliary  forces,  the 
abdominal  and  other  muscles  concerned,  are  at  fault.  It  is  not 
uncommon  in  very  stout  individuals  and  in  women  with  pendulous 
-abdomens,  and  feeble  or  widely  separated  recti.  Again,  it  is  very 
common  in  nervous 'and  excitable  women,  and  in  those  who  bear 
pain  badly  or  feel  pain  acutely.     But  the  expulsive  forces  are  some- 


10  OPERATIVE   MIDWII'KIIY 

times  inhibited  by  such  simple  conditions  as  overdistension  of  bladder 

or  rectum,  and  one  Frequently  sees  strong  bearing-down  efforts  follow 
the  emptying  of  these  viscera.  It  must  not  be  forgotten,  however, 
that  a  considerable  amount  of  the  strength  of  the  uterine  contractions 
and  the  auxiliary  forces  in  the  second  stage  is  reflexly  set  up  by  the 
mechanical  stimulus  of  the  presenting  part  upon  the  pelvic  floor. 
Feebleness  of  the  forces  is  therefore  not  infrequently  the  result  of 
non-descent  of  the  presenting  part.  Every  one  is  familiar  with  the 
effect  which  the  introduction  of  the  hand  or  a  blade  of  the  forceps  has 
on  the  forces.  Such  treatment  is  seldom  employed  in  the  present  day, 
although  it  was  a  common  practice  in  ancient  times. 

The  recognition  of  uterine  inertia  is  not  difficult,  provided  one 
makes  it  a  rule  always  to  exclude  the  possibility  of  other  pathological 
conditions  being  the  cause,  and  only  concluding  that  the  forces  are  at 
fault  when  there  is  nothing  else  to  account  for  the  protraction  of  the 
labour.  If  this  precaution  is  not  taken  mistakes  will  constantly  be  made. 

The  operator,  when  it  is  a  question  of  uterine  inertia,  should  note 
the  frequency  and  duration  of  the  uterine  contractions.  Unfor- 
tunately, there  is  no  standard  for  comparison.  Every  individual  is 
a  law  unto  herself,  and  sometimes,  even  the  character  of  the  parturi- 
tion, varies  in  different  labours  in  the  same  individual.  As  labour 
progresses  there  should  be  an  increase  in  the  frequency,  severity,  and 
duration  of  the  uterine  contractions,  and  there  should  be  a  stead}7 
descent  of  the  fretus.  Frequently  the  uterine  activity  ceases  for  a 
time,  and  it  will  be  found  advantageous  to  encourage  this  by  the 
administration  of  a  full  dose  of  opium  or  morphia.  After  such  a  lapse 
the  uterus  resumes  its  activity,  and  labour  progresses  rapidly. 

As  regards  the  treatment  of  inertia  of  the  uterus  there  is  little  to 
be  said,  and,  unfortunately,  not  a  great  deal  to  be  done. 

As  protraction  of  the  first  stage  of  labour  causes  no  concern,  it 
will  be  found  best  not  to  interfere  beyond  removing  any  condition 
which  may  be  reflexly  inhibiting  the  uterine  activity-  Thus,  it  is 
important  to  keep  the  bladder  and  bowels  empty,  and  to  remove  any 
irregular  uterine  contractions — the  so-called  '  false  pains  ' — by  small 
doses  of  opium  or  morphia.  Often  a  change  in  position  is  useful,  and 
usually  in  this  stage  the  most  progress  is  made  when  the  parturient 
keeps  moving  about. 

Many  stimulants  to  uterine  contraction  have  been  suggested. 
Amongst  them  may  be  mentioned  irritation  of  the  breasts,  massage 
of  the  uterus,  electricity,  hot  vaginal  douches,  separation  of  the 
membranes,  rupture  of  the  membranes,  dilatation  of  the  cervix  by 
means  of  the  hand  or  metal  dilators,  and  the  administration  of 
various  drugs  having  a  special  effect  upon  uterine  activity.     Of  great 


INEFFICIENCY  OF  THE  FOKCES  11 

antiquity  are  the  two  first  methods,  and  certainly  both,  but  especially 
the  second,  at  fixed  intervals,  bring  about  uterine  contractions.  It  is 
very  questionable,  however,  if  they  advance  labour  to  any  great 
extent.  From  electricity  little  better  results  are  obtained.  The  safest 
manner  in  which  it  can  be  employed  is  to  apply  one  pole  over  the 
uterus  and  the  other  over  the  dorsal  vertebra?.  The  introduction  of 
an  electrode  into  the  vagina  is  undesirable.  Some  favour  the  con- 
tinuous and  others  the  faradic  current,  but  only  a  few  electrical 
enthusiasts  consider  the  treatment  of  any  practical  service. 

The  various  devices  of  irritating  the  uterus  by  stimulating  the 
cervix  are  sometimes  of  value.  Hot  vaginal  douches,  especially  if 
there  is  any  undue  resistance  in  the  soft  parts,  are  often  of  decided 
benefit.  Separation  of  the  membranes  from  the  lower  portion  of  the- 
uterus,  the  injection  of  glycerine,  and  manual  or  mechanical  dilata- 
tion of  the  cervix,  do  not  come  into  consideration  here,  for,  properly 
speaking,  they  are  methods  of  inducing  labour.  They  will  be  con- 
sidered, therefore,  when  that  subject  is  under  discussion. 

As  regards  the  drugs  which  have  been  recommended  and  employed 
for  the  purpose  of  stimulating  uterine  contractions,  ergot  and  quinine 
are  the  most  important.  Some  others,  such  as  pilocarpin  and  ipecac- 
uanha, have  a  similar  effect,  but  only  the  two  first  mentioned  are  now 
used.  Of  these  the  more  important  is  ergot,  in  the  form  of  the  liquid 
extract,  or  ergotin.  Ergot  given  in  full  doses  produces  uterine  con- 
tractions of  a  tetanic  nature.  Every  one  knows  this  from  clinical 
experience,  and  Schatz  many  years  ago  demonstrated  it  by  means  of 
his  tokodynamometer.  By  one  and  all,  therefore,  it  is  condemned. 
That  matter  was  settled  long  ago  once  and  for  all. 

The  administration  of  ergot  in  small  doses  is  another  matter. 
Satisfactory  results  have  been  obtained  by  Schatz,  Schaffer,  and  More 
Madden.  In  spite  of  the  experience  of  these  observers,  however,  it  is 
generally  condemned. 

Several  writers  have  reported  favourably  of  quinine  sulphate, 
given  in  two  or  three  doses  of  from  2  to  4  grains.  Larger  doses  do 
not  seem  to  give  any  better  results.  It  is  claimed  that  the  uterine 
contractions  produced  by  the  drug  do  not  present  the  unfavourable 
features  which  follow  the  administration  of  ergot.  Personally,  I  have- 
been  disappointed  with  the  results. 

But  of  all  methods  of  treatment  the  only  really  valuable  one  in  my 
experience  is  the  procuring  for  the  '  tired  '  uterus  a  period  of  rest. 
This  is  best  accomplished  by  the  administration  of  opium  or  chloral- 
After  a  varying  interval  the  uterus  refreshed  begins  once  again  to 
3ontract  strongly.  When  this  recurrence  of  activity  is  established, 
;he  nature  and  effect  of  the  uterine  contractions  should  be  carefully 


12  OPERATIVE   Ml  I  >\YIFEl:Y 

observed,  and  if  they  have  any  tendency  to  become  '  tetanic '  the 
uterus  should  be  immediately  emptied.  If  after  a  short  interval 
they  still  seem  to  be  having  little  effect  in  advancing  the  labour, 
further  delay  is  profitless.  When  the  uterus  is  emptied  after  a  period 
of  rest  and  after  active  contractions  have  recurred,  there  is  little  danger 
of  post-partum  haemorrhage. 

All  the  methods  of  treatment  which  have  been  considered  may  be 
employed  in  both  stages  of  labour.  When,  however,  the  second  stage 
has  been  reached,  other  manauvres  may  be  tried,  for  then  the 
auxiliary  forces  have  likewise  to  be  stimulated.  Amongst  the  devices 
to  stimulate  the  latter  may  be  mentioned  mechanical  irritation  of 
the  vagina  and  perineum  by  the  colpeurynter  or  the  hand.  The 
latter  of  these  is  never  employed  at  the  present  day.  As  regards 
the  colpeurynter,  however,  it  is  frequently  employed,  especially  on 
the  Continent.  Burger1  refers  to  it  favourably.  The  only  form  of 
mechanical  stimulation  extensively  employed  is  massage  of  the  uterus 
at  regular  intervals.     I  have  never  seen  it  do  much  good. 

Encouraging  the  patient  to  bear  down,  and  removing  any  reflex 
condition  which  may  be  inhibiting  the  action  of  the  forces,  has  often 
a  very  beneficial  effect.  Especially  is  this  seen  in  cases  where  the 
parturient  is  very  nervous  and  excitable,  and  complains  greatly  of 
the  pain  of  the  uterine  contractions.  Thus,  it  will  be  found  that 
inhalations  of  small  quantities  of  chloroform  are  of  great  service.  It 
is  surprising  how  such  treatment  is  often  followed  by  strong  expul- 
sive efforts.  But  in  other  cases,  when  the  symptoms  mentioned  are 
not  present,  chloroform  retards  the  labour. 

Before  leaving  the  subject  of  uterine  inertia,  an  important  question 
must  be  considered — viz.,  how  far  does  inertia  justify  one  in  having 
recourse  to  artificial  delivery  ?  As  regards  this  matter  there  are 
two  distinct  opinions.  There  are  those  who  maintain  that  inertia 
per  se  is  never  a  sufficient  indication,  and  that  one  must  wait  until  the 
maternal  pulse  and  temperature  is  disturbed,  or  until  the  fu-tal  heart 
shows  signs  of  being  injuriously  affected.  On  the  other  hand,  there 
are  those  who  recommend  interference  before  these  symptoms  mani- 
fest themselves.     They  try  to  anticipate  the  symptoms. 

What  are  the  facts  of  the  case '?  The  effect  of  uterine  inertia  is  to 
prolong  labour,  which  in  itself  adds  materially  to  the  discomfort  of 
the  parturient.  If  it  is  only  the  first  stage  that  is  affected,  nothing 
further  results  ;  neither  the  mother  nor  the  child  is  endangered  except 
when  the  membranes  rupture  prematurely,  and  even  in  such  cases 
there  is  a  tendency  to  exaggerate  the  danger.  As  regards  the  second 
stage,  the  real  trouble  in  private  practice  is  that  unusual  delay  is 
1  Arcln'r  f.  Qyn.,  Bd.  lxxvii.,  Heft  >5.,  p.  54G. 


INEFFICIENCY  OF  THE  FORCES  13 

an  inconvenience  to  the  patient  and  those  in  attendance.  The  risk  of 
infection  in  such  cases  is  increased,  largely  because  vaginal  examina- 
tions are  made  at  short  intervals,  with  the  object  of  ascertaining  if  any 
progress  is  being  made.  The  dangers  to  the  child  and  the  soft  parts 
of  the  parturient  canal  are  not  so  great  as  is  generally  imagined.  On 
theoretical  grounds,  therefore,  non-interference  is  clearly  the  right 
attitude.  It  is  an  attitude  which  is  logical,  and  serves  as  a  good 
working  rule  for  one's  guidance,  and  I  have  every  sympathy  with 
those  who  adopt  it.  Still,  in  spite  of  that,  I  follow  in  practice  those 
who  consider  that  prolongation  of  the  second  stage  to  several  hours 
is  sufficient  reason  for  operative  interference  in  cases  in  which 
there  is  no  disproportion  between  foetus  and  maternal  pelvis.  My 
position  is  that  the  human  body  is  not  a  machine,  and  it  cannot  be 
treated  as  such.  The  temperature  and  pulse  may  be  very  considerably 
disturbed  during  labour,  or  even  before  labour  commences,  or  they 
may  respond  slowly  to  the  irritation  of  labour.  As  regards  the  child, 
my  experience  of  a  prolonged  labour  is,  that  if  one  waits  until  the 
foetus  shows  signs  of  circulatory  disturbances,  it  will,  when  delivered, 
be  more  asphyxiated  than  was  expected. 

I  hope  there  is  no  misunderstanding  regarding  my  attitude,  or  a 
belief  that  I  favour  early  interference.  Early  interference  in  the  second 
stage,  unless  there  is  some  decided  indication  for  it,  in  mother  or  child, 
cannot  be  too  strongly  condemned.  Without  doubt,  it  is  responsible 
for  many  of  the  minor  ailments  which  follow  parturition,  as  it  certainly 
is  the  cause  of  vaginal  and  perineal  lacerations,  which  might  have  been 
avoided  by  allowing  the  pelvic  floor  to  become  gradually  distended  by 
the  presenting  part. 

Tetanic  Contractions  of  Uterus.1 — It  sometimes  happens  that 
the  uterine  contractions  are  irregular  in  character.  We  meet  with 
this  in  two  forms — general  tetanic  contraction  of  the  uterus,  and 
spasmodic  local  contraction. 

Tetanic  contraction  of  the  uterus  (tetanus  uteri)  is  a  condition  seen 
in  certain  cases  of  extreme  dystocia,  when  the  uterus  has  been  long 
trying  to  overcome  the  obstruction  to  the  birth  of  the  child.  Thus,  one 
sees  it  in  marked  degrees  of  pelvic  deformity  and  in  impacted  trans- 
verse presentations.  One  also  encounters  it  when  ergot  has  been 
freely  administered.  Such  a  condition  is  to  be  distinguished  from  the 
ordinary  form  of  retraction  of  the  uterus  found  after  the  membranes 
have  ruptured,  by  the  fact  that  it  is  associated  with  great  pain  and 
iiscomfort,  and  a  uterus  uniformly  convex  and  tender  to  pressure. 

1  The  most  valuable  paper  on  this  subject  in  the  English  language  is  by 
Braxton  Hicks,  'On  the  Condition  of  the  Uterus  in  Obstructed  Labour.'  Trans- 
ictions  Obstet.  Soc.  London,  vol.  ix.,  p.  207. 


14  OPERATIVE  MIDWIFERY 

This  complication  is  one  of  extreme  gravity,  and  as  a  matter  of 
fact,  is  usually  the  result  of  mismanagement.  A  uterus  should  not 
he  allowed  to  get  into  a  condition  of  tetanus.  AY  hen  this  occurs,  the 
first  thing  to  do  is  to  moderate  the  contractions  hy  inhalations  of 
chloroform  and  a  hypodermic  injection  of  morphia.  By  such  means 
the  tetanic  contractions  can  always  be  relieved.  The  delivery  should 
be  completed  immediately  in  the  safest  manner  possible,  and  here  it 
may  be  remarked  that,  as  the  child  will  almost  certainly  be  dead  or 
dying,  too  much  consideration  need  not  be  given  it.  If  the  tetanic 
•contractions  have  been  present  for  some  time,  one  must  always  be 
prepared  for  post-partum  haemorrhage,  and  post-partum  haemorrhage 
of  a  very  troublesome  character.  If  there  is  any  suspicion  of  rupture 
of  the  uterus,  the  uterus  must  be  carefully  examined. 

Localized  contractions  of  the  uterus,  the  other  form  of  irregular 
•contraction,  are  of  interest  both  in  pregnancy  and  labour.  They  are 
specially  liable  to  occur  in  the  three  regions  where  the  circular 
muscular  fibres  are  pronounced — viz.,  the  orifices,  the  os  internum 
and  externum,  and  the  openings  of  the  Fallopian  tubes.  In  pregnancy 
such  contractions  about  the  Fallopian  tubes  have  frequently  led  to 
errors  in  diagnosis,  for  on  bimanual  palpation  the  irregular  swelling 
closely  resembles  an  interstitial  myoma  or  an  extra-uterine  pregnancy. 
Bar1  has  specially  referred  to  these  irregular  contractions,  and  I 
have  witnessed  the  occurrence  on  many  occasions. 

During  labour  such  localized  spasmodic  contractions  often  cause 
considerable  discomfort,  and  when  they  occur  about  the  retraction 
ring  (strictura  uteri),  or  about  the  external  os  (trismus  uteri,  spasmodic 
rigidity  of  the  cervix),  they  may  actually  interfere  with  the  birth  of 
the  child. 

Spasmodic  contraction  of  the  retraction  ring  usually  follows  a 
protracted  labour  in  which  the  passage  or  passenger  is  at  fault.  The 
retraction  ring  may  sometimes  be  so  applied  to  the  child  as  to  arrest 
its  expulsion,  when  the  presentation  is  by  the  breech  or  by  the  head, 
while  in  the  third  stage  retention  of  the  placenta  is  a  common  sequela. 
These,  like  other  varieties  of  irregular  uterine  contractions,  are 
relieved  by  chloroform,  opium  or  morphia. 

1  Bulletin  de  la  Soc.  d'Obstet.  de  Paris,  February  16,  1905. 


CHAPTER  III 

DYSTOCIA  THE  RESULT  OF  FAULTS  IN  THE  FCETUS 

Attitude,  Position,  and  Presentation  —  Abdominal  Palpation — 
Vaginal  Examination  —  Auscultation  —  Other  Methods  of 
Examination. 

Amongst  the  commonest  causes  of  dystocia  attributable  to  the  foetus 
are  alterations  in  its  attitude,  position,  and  presentation. 

Each  of  these  terms  has  its  particular  significance.  Attitude  is 
the  relationship  of  the  different  parts  of  the  child  to  one  another. 
Presentation  is  the  relationship  of  the  long  axis  of  the  child  to  the  long 
axis  of  the  uterus.  Position  is  the  relationship  which  a  particular  part 
of  the  child  bears  to  a  particular  part  of  the  pelvic  wall.  Thus,  we 
consider  the  child  in  the  normal  attitude  when  it  lies  flexed  with  its 
chin  against  the  sternum  and  its  upper  and  lower  limbs  folded  across 
the  upper  and  lower  parts  of  its  trunk;  in  the  normal  presentation 
when  it  lies  longitudinally  with  its  head  lowermost ;  and  in  the  normal 
position  when  the  long  axis  of  its  head  lies  in  the  right  oblique 
diameter  of  the  pelvis  with  the  occiput  anterior  (Fig.  4). 

Abdominal  Palpation.  —  To  make  out  differences  in  attitude, 
position,  and  presentation  is  not  always  easy,  and  is  especially 
difficult  if  one  depends  entirely  on  the  older  method  of  vaginal 
examination.  Indeed,  by  such  an  examination,  nothing  can  be  made 
out  so  long  as  the  os  is  undilated  and  the  presenting  part  is  high  in 
the  pelvis.  Labour  must  have  advanced  some  way  before  anj^thing 
can  be  affirmed  regarding  the  presenting  part. 

With  the  newer  method  of  examination  by  abdominal  palpation 
it  is  quite  otherwise,  for  during  pregnancy  and  early  in  labour,  the 
presentation  and  position  of  the  child  can  generally  be  defined  without 
much  difficulty.  But  abdominal  examination  possesses  another  advan- 
tage over  the  vaginal.  It  renders  repeated  vaginal  examinations  less 
necessary,  and  diminishes  the  risks  of  infection.  Indeed,  it  is  in  great 
part  because  of  this  that  it  has  come  into  such  favour. 

15 


„ 


16 


OPKRATIYi:   MIDWIlTJlY 


The  two  obstetricians  whose  names  are  especially  connected  with 
the  perfecting  of  this  method  are  Pinard  in  France  and  Leopold  in 
(iermany.     The  most  valuable  monograph  in  the  English  language  i& 


Fig.  l — From  a  Dissection  of  a  Uterus  at  Term,     The  Woman  died  of  Eclampsia. 
(Photograph  l>y  Dr.  James  Scott.) 


one  by  McLennan,1  of  Glasgow,  who  has  considered  the  subject  most 
exhaustively  and  given  a  complete  literature. 

To  practice  abdominal  palpation  with  a  view  to  making  out  the 
exact  position  and  presentation  of  the  fu-tus  it  is  necessary  to  place 

1  'Abdominal  Manipulations  in  Pregnancy,'  London,  1902. 


ABDOMINAL  PALPATION 


17 


the  patient  to  be  examined  on  her  back  with  the  head  slightly 
raised.  The  bladder  must  be  emptied  shortly  before  the  examination, 
and  the  woman  must  be  perfectly  comfortable  and  breathe  quite 
freely. 

The  accoucheur,  after  heating  his  hands  in  warm  water,  should 
place  them  on  the  patient's  abdomen.  At  first  the  pressure  should 
be  gentle,  but  it  may  be  increased  gradually.  It  is  of  great  im- 
portance to  avoid,  as  far  as  possible,  setting  up  uterine  contractions 
and  spasms  in  the  abdominal  muscles.  It  will  tend  to  relaxation  of 
the  abdominal  wall  if  the  patient's  attention  is  diverted,  and  when 
moving  the  hands  from  one  place  to  another  if  they  are  slid  over  the 
surface,  not  lifted  and  suddenly  planted  down  again.     It  should  be 


Fig.  5.— Palpation  of  the  Fcetal  Part  situated  at  the  Pelvic  Brim. 


remembered,  also,  that  it  is  not  the  tips  of  the  fingers  which  are  to 
be  used,  but  their  whole  palmar  surface,  and  that  while  one  hand 
is  making  out  what  is  beneath  it,  the  other  steadies  the  distended 
organ. 

The  parts  of  the  child  which  require  to  be  located  are  the  head, 
breech,  limbs,  and  back. 

The  first  manoeuvre  or  'grip,'  which  has  for  its  object  the  location 
of  the  fcetal  parts  situated  over  the  brim,  is  carried  out  by  passing 
the  two  hands  down  along  the  sides  of  the  uterus  towards  the  brim 
of  the  pelvis.  To  do  this  the  accoucheur  should  stand  or  sit  at  the 
right  side  of  the  patient  (Fig.  5).     In  most  cases  the  head  will  be 

2 


is  o|'i:i;ativk  midwiit.ky 

found  at  the  brim,  and  will  he  recognized  as  a  large,  hard,  globular 
mass.  The  beginner  must  make  sure  that  it  is  really  the  pre 
senting  head  and  not  the  pelvic  brim  he  feels.  The  pelvic  brim 
should  therefore  be  defined,  and  then  the  fingers  slipped  over  it 
on  to  the  presenting  part,  when  a  depression  will  be  found  between 
the  brim  and  the  head,  if  the  head  has  descended  low  into  the  pelvis, 
and  especially  if  the  uterus  is  very  tense,  it  may  be  dillicult  to  feel 
the  head,  and  the  mistake  may  be  made  of  thinking  that  there  is  no 
part  of  the  child  engaging.  It  will  often  be  found  that  the  head  can 
be  grasped  better  by  making  what  is  termed  the  '  Pawlik  grip.'  To 
carry  this  out  the  examiner  should  face  the  patient  and  grasp  the 


Fig.  0.  — '  Pawlik  Grip.' 

presenting  part  between  the  thumb'  and  fingers  of  one  hand,  while 
steadying  the  child  with  the  other  (Fig.  6). 

Having  made  out  the  presenting  part,  and  supposing  it  to  be  the 
head,  while  still  facing  the  patient,  the  hands  should  be  slid  up  to 
either  side  of  the  fundus  (Fig.  7),  where  usually  the  breach  is  situated. 
This  part  is  felt  to  be  bulkier,  but  less  globular,  and  to  have  a  depres- 
sion between  two  prominences. 

The  sides  of  the  distended  uterus  are  next  examined  (Fig.  8). 
They  will  be  found  occupied,  the  one  by  the  trunk  and  the  other  by 
the  limbs.  On  the  side  towards  which  the  trunk  is  directed  there  is 
greater  resistance,  and  the  trunk  is  recognized  as  a  long,  smooth  mass, 
curving  round  and  running  into  the  head  and  breech.  A  break  in 
continuity  can  usually  be  recognized  between  trunk  and  head,  and. 
unless  the  head  is  fixed  at  the  brim,  there  is  considerable  mobility 


ABDOMINAL  PALPATION 


1«» 


between  it  and  the  trunk.  At  the  pelvic  extremity  the  back  runs  right 
into  the  breech  without  any  break  in  continuity,  and  there  is  no 
mobility  between  the  breech  and  the  rest  of  the  trunk. 

On  the  other  side  of  the  abdomen,  and  often  more  posterior, 
are  the  limbs.  Here  the  resistance  is  very  much  less,  and  different 
members  can  be  felt,  sometimes  at  rest,  but  often  gliding  under- 
neath the  hand  or  being  pushed  up  by  more  violent  movements  of  the 
foetus. 

From  this  brief  description  abdominal  palpation  seems  very  simple, 
but  it  is  not  always  so.  If  the  abdominal  walls  are  thick  or  rigid, 
and  if  the  uterus  is  very  tense  or  irritable,  contracting  at  the  slightest 


F ig.  7. — Palpation  of  the  Fretal  Part  situated  at  the  Fundus. 


touch,  it  maybe  extremely  difficult,  and  sometimes  impossible,  to  make 
out  the  foetal  parts.  Also,  if  the  foetus  is  very  small  and  the  liquor 
amnii  excessive,  little  can  be  felt.  Still,  with  practice,  it  is  surprising 
how  much  can  be  made  out  even  when  the  conditions  are  by  no  means 
favourable. 

After  the  accoucheur  has  had  some  experience  in  abdominal  palpa- 
tion, he  will  find  that  he  can  go  a  step  further,  and  actually  diagnose 
the  position  and  attitude  of  the  presenting  head  or  breech.  To  some 
extent  this  may  be  done  by  the  beginner  from  the  position  of  the 
back  and  limbs,  although  in  head  presentation  this  does  not  permit 
of  great  exactness.  The  head  must  be  fixed  at  the  brim  before  one 
can  pronounce  definitely  regarding  its  position.  If  one  looks  at  the 
illustration  (Fig.  9),  it  will  be   observed  that  in  vertex  positions,  the 


20 


OPERATIVE  MIDWIFERY 


occipital  end  of  the  head  being  lowermost,  the  fingers  can  be  sunk 
deeper  into  the  pelvis  on  that  side,  or,  to  put  it  differently,  the  Bide 
on  which  the  fingers  sink  deepest  is  the  side  to  which  the  occiput  is 
directed.  In  face  and  brow  presentations,  as  we  shall  see,  it  is  quite 
otherwise.  With  them  the  occiput  is  higher,  and  is  felt  unusually 
prominent.  These  and  other  points,  however,  will  be  considered  in 
connexion  with  the  different  positions  and  presentations.  Similarly, 
the  appreciation  of  the  relative  size  of  the  foetal  head  and  maternal 
pelvis,  so  important  a  guide  to  treatment,  and  the  appreciation  of 
the  presence  of  more  than  one  fcetus,  will  be  considered  when  these 
subjects  are  under  discussion. 

Vaginal  Examination. — Cntil  recent  years  the  accoucheur  made 
his  diagnosis  of  the  position,  presentation,  etc.,  of  the  fcetus  entirely 


]    Fig.  8. — Palpation  of  the  Fcetal  Part  situated  at  the  Sides  of  the  Uterus. 


by  a  digital  examination  per  vaginam.     If  one  looks  at  the  obstetric 
textbooks  of  a  comparatively  few  years  ago,    one  finds  this  method 
of  examination  the  only  one  seriously  discussed,  while  even  at  the 
present  moment  a  large  majority  of  practitioners  still  employ  it  almost 
exclusively. 

The  perfecting  of  abdominal  palpation,  but,  above  all,  the  demon- 
stration that  every  vaginal  examination  is  a  distinct  danger  to  the 
parturient,  has  led  the  more  enlightened  and  thoughtful  to  limit 
vaginal  examinations  as  far  as  possible.  Some  enthusiasts  would 
dispense  with  the  latter  altogether  ;  but  it  is  perfectly  evident  that 
such  an  extreme  position  is  untenable,  for  there  are  many  conditions, 
both  maternal  and  foetal,  which  can  only  be  appreciated  by  vaginal 
examination.  Amongst  these  may  be  mentioned  small  tumours  in 
the  pelvis,  rigidity  of  the  cervix,  and,  indeed,  not  infrequently,  many 


VAGINAL  EXAMINATION 


21 


slighter  abnormal  attitudes  and  positions  of  the  foetus.  Prolapse  of 
the  cord  is  another  condition  which  can  only  be  early  appreciated 
by  vaginal  examination.  Undoubtedly  by  careful  auscultation  one  can 
tell  when  the  child  is  in  danger,  but  in  cases  of  prolapse  of  the  cord  if 
one  were  to  wait  until  the  child  showed  symptoms  of  cardiac  embarrass- 
ment there  would  be  little  chance  of  saving  it.  An  early  diagnosis 
•of  the  condition  is  only  possible  by  vaginal  examination. 

Having  said  so  much  in  favour  of  vaginal  examination,  it  must  be 


Fig.  9. — The  Occiput  is  located  by  the  Hand — in  this  Particular  Case  the  Left — sinking 
deeper  into  the  Pelvis  upon  the  Side  towards  which  it  is  directed. 


clearly  understood  that  the  number  of  examinations  should  be  as  few 
as  possible.  Usually  only  two  are  necessary,  one  early  in  labour  and 
the  other  after  the  membranes  have  ruptured.  Again  let  me  say  that 
^very  vaginal  examination  during  labour  distinctly  increases  the  risks 
of  sepsis.  One  cannot  get  away  from  that  fact ;  it  has  been  proved 
beyond  all  question.  I  have  no  intention,  however,  of  discussing  at  this 
stage  the  question  of  septic  infection  and  how  to  prevent  it.  That 
matter  is  fully  considered  in  Chapter  XXI. 


2  2 


OPERATIVE  MIDWIFERY 


Prior  to  making  a  vaginal  examination,  it  is  always  desirable, 
when  possible,  that  the  woman's  bladder  and  rectum  should  be  well 
emptied.  The  appearance  of  the  abdomen  when  the  bladder  is  over- 
distended  is  shown  in  the  illustration  (Fig.  10). 

The  accoucher's  band  and  the  patient's  vulva  are  thoroughly 
cleansed.  In  order  to  lessen  still  further  the  risks  of  infection,  the 
fingers  of  one  hand  should  hold  apart  the  labia,  so  as  to  permit  of 
one  or  two  fingers  of  the  other  hand  being  introduced  without  any 
friction  against  the  external  genitals.  The  vulva  should  be  fully 
exposed  in  making  the  examination. 

The  position  which  the  patient  should  assume  is  a  matter  entirely 


Fio.  10. — An  Overdistended  Bladder  in  a  Parturient  at  Term 


of  choice.  We,  in  this  country,  favour  the  left  lateral,  but  obstet- 
ricians in  other  countries  generally  prefer  the  dorsal.  Whenever  a 
thorough  bimanual  examination  of  the  pelvis  early  in  pregnancy  is 
required,  the  dorsal  is  usually  better,  although  I  have  occasionally 
found  in  stout  women  that  the  pelvic  contents  may  he  more  exactly 
felt  in  a  position  midway  between  the  dorsal  and  lateral. 

If  the  vaginal  examination  is  being  made  for  the  first  time  upon  th< 
parturient,  the  general  formation  of  the  bony  pelvis  and  the  condition 
of  the  soft  parts  should  be  investigated.  It  is  most  desirable  in  the 
case  of  a  primipara  and  of  a  multipara,  who  has  had  any  difficulty  in 
her  previous  labours,  that  this  examination  should  be  made  some  few 
weeks  before  term,  for  now  and  again  some  abnormality  will  be  dis- 


AUSCULTATION  28 

covered  which,  if  recognized  for  the  first  time  during  labour,  might 
be  difficult  to  treat.  Personally,  I  examine  vaginally  every  primi- 
para  about  the  thirty-sixth  week.  At  the  same  time  I  determine  the 
presentation  and  position  of  the  child  by  abdominal  palpation. 

Having  formed  an  opinion  of  the  pelvis,  the  soft  parts  of  the 
parturient  canal,  and  the  consistency  of  the  cervix  and  the  degree 
of  its  dilatation,  the  particular  presentation  is  determined.  The 
various  landmarks  of  the  foetal  skull — the  sutures,  fontanelles,  bony 
and  other  prominences — are  familiar  to  all.  I  must  admit  that 
occasionally  I  have  not  been  able  to  come  to  a  diagnosis  regarding 
the  position,  from  them  alone ;  especially  has  this  been  so  when  there 
has  been  any  defective  ossification  of  the  cranial  bones,  and  the  head 
has  been  situated  high  in  the  pelvis.  In  cases  of  doubt,  therefore, 
and  especially  prior  to  any  operative  interference,  I  always  feel  for 
the  ear.  This  landmark  is  not  much  employed  at  the  present  day, 
but  the  older  obstetricians — Baudelocque,  Smellie,  and  others — often 
made  use  of  it,  and  I  have  found  it  of  great  service.  The  features  of 
the  different  presentations  are  referred  to  elsewhere. 

In  addition  to  determining  the  size,  position,  and  presentation  of 
the  foetal  head,  the  examining  finger  should  always  be  swept  round 
to  make  sure  that  there  is  no  prolapsed  loop  of  cord  or  other  abnormal 
condition. 

Auscultation. — In  the  few  remarks  which  are  called  for  in  con- 
nexion with  the  examination  by  auscultation  I  shall  confine  myself 
entirely  to  the  foetal  heart  sounds.  It  is  well  known  that  other  sounds 
may  be  heard  with  the  stethoscope — the  uterine  souffle,  the  funic 
souffle,  movement  of  the  child,  muscular  susurrus,  gas  in  the  uterus, 
bruit  of  placental  separation.  None  of  them,  however,  is  of  any  real 
practical  importance. 

The  careful  and  repeated  auscultation  of  the  foetal  heart  during 
labour,  and  especially  when  the  second  stage  is  protracted,  cannot 
be  too  strongly  commended.  The  child  seldom  dies  quickly.  Death 
occurs  gradually,  and  so,  as  a  rule,  one  has  opportunities  to  interfere 
and  save  the  child.  Almost  the  only  occasions  upon  which  the  child 
dies  quickly  during  labour  are  where  the  cord  becomes  prolapsed 
and  continuously  pressed  upon — say  when  the  membranes  rupture 
before  full  dilatation  of  the  os. 

One  knows  that  the  child's  life  is  in  danger  when  the  heart 
sounds  become  slower.  Sometimes  for  a  little  they  become  faster, 
but  before  long,  if  the  foetal  heart  is  embarrassed,  the  sounds  become 
slower  and  slower,  and  then  intermittent,  irregular,  and  still  slower. 
Whenever  they  number  less  than  110  the  child's  life  is  decidedly  in 
danger,  and  the  sooner  it  is  extracted  the  better.     It  is  often  difficult 


21 


OPERATIVE  MIDWII  l.l;V 


to  count  the  fietal  heart  if  it  is  registering  1  1<>  to  160,  hut  when  it 
comes  down  to  100  to  110  it  is  an  easy  matter.  The  only  possible 
mistake  is  to  confuse  it  with  the  maternal  pulse.  In  a  protracted 
lahour  the  foetal  heart  should  he  carefully  noted  every  half-hour 
during  the  second  stage. 

But  there  is  valuahle  information  to  be  gained  from  the  heart 
sounds  regarding  other  conditions.  The  diagnosis  of  the  presence  of 
more  than  one  fcutus  is  confirmed  by  hearing  fcetal  heart  sounds  of 


Fig.  11. — Areas  of  Maximum  Intensity  of  the  Foetal  Heart  Sounds  in  Pelvic  and  Vertex 

Positions. 

The  line  marks  the  uppermost  limit  for  head  presentations  and  the  lowermost  for  breach. 


different  rhythms.     This,  however,  is  considered  in  the  chapter  on 
Plural  Pregnancy  (Chapter  VIII.). 

The  fu'tal  heart  sounds  are  also  of  value  in  the  diagnosis  of  the 
various  presentations.  The  illustration  (Fig.  11)  shows  the  area  of 
greatest  intensity  for  the  different  presentations.  It  may  generally 
be  concluded  that  in  all  presentations  except  the  face  the  sounds  are 
heard  best  wherever  the  back  of  the  child  is  situated.  In  face 
presentations,  however,  the  sounds  may  be  best  heard  over  the  thorax, 
and  occasionally  the  foetal  heart  has  been  felt  through  the  uterine 
wall  in  this  presentation. 


RECTAL  EXAMINATION  25 

A  rectal  examination  is  rarely  if  ever  called  for  in  obstetric 
practice.  With  backward  displacement  of  the  gravid  uterus  and 
■certain  tumours  complicating  pregnancy,  it  is  conceivable  that  it 
might  be  of  service.  For  example,  where  a  myoma  happened  to  be 
•on  the  anterior  uterine  wall,  and  prevented  palpation  or  auscultation 
of  the  fu'tus,  as  was  my  experience  some  time  ago  (Fig.  123),  a 
rectal  examination  might  permit  one  feeling  the  foetal  parts. 


CHAPTER  IV 

DYSTOCIA  THE  RESULT  OF  FAULTS  IN  THE  FCETUS— Continued 

Abnormal  Attitude  and  Position  of  the  Head  —Prolapse  of 
Limbs  associated  with  Presentations  of  the  Head. 

ABNORMAL  PEESENTATIONS  OF  THK  VERTEX 

Oceipito-Posterior  Positions  of  the  Vertex. — The  presentations  of 
the  vertex  associated  with  dystocia  are,  with  few  exceptions,  those  in 
which  the  occiput  is  directed  backwards  (Fig.  12).  It  is  of  very 
frequent  occurrence.  I  have  found  it  in  fully  20  per  cent,  of  my 
private  cases. 

As  regards  its  etiology,  nothing  very  definite  is  known.  Theoreti- 
cally, the  malrotation  is  more  liable  to  occur  if  the  pelvis  is  relatively 
large  or  the  f<jetal  head  relatively  small — in  other  words,  if  the  head 
is  still  extended  when  it  reaches  the  pelvic  floor.  There  is  distinct 
support  for  this  explanation  in  the  fact  that,  according  to  most  writers, 
the  average  size  of  the  fcetal  head  in  children  born  with  the  occiput 
posterior  is  somewhat  below  the  normal.  Yon  Weiss,1  for  example, 
found  this  so  in  41  per  cent. 

The  recurrence  of  the  presentation  in  succeeding  labours  has  been 
frequently  remarked  upon,  and  recently  a  case  came  under  my  notice 
where  it  was  repeated  at  three  successive  parturitions. 

The  malposition  being  so  common,  it  is  of  great  importance  that 
one  should  be  able  to  recognize  it.  Early  in  labour  this  is  only 
possible  by  abdominal  palpation,  but  after  the  head  has  sunk  into  the 
pelvis  and  the  os  is  well  dilated,  vaginal  examination  reveals  the 
anterior  fontanelle  within  easy  reach  and  towards  the  front  of  the 
pelvis. 

When  palpating  the  abdomen,  and  after  satisfying  oneself  that 
the  presentation  is  a  head,  three  things  should  always  lead  one  to 
suspect  an  occipito-posterior  position :  ease  in  palpating  the  limbs  in 
front,  the  presence  of  the  back  on  the  right  side  of  the  abdomen, 
and  a  depression  between  the  upper  and  lower  poles  of  the  fcetal 

1  Volkmann's  Samml.  Kim.  Vortrage,  No.  60,  1892. 
26 


ABNORMAL  PRESENTATIONS  OF  THE  VERTEX    27 

ovoid.  Sometimes  it  is  impossible  to  palpate  the  back,  as  only  the 
edge  of  the  trunk  is  within  reach  ;  in  other  cases,  however,  the  back 
is  more  to  the  front,  and  can  therefore  be  readily  felt.  If  conditions 
are  favourable  for  abdominal  palpation,  one  is  sometimes  able  to  feel 
the  point  of  the  chin,  as  in  this  position  the  head  enters  the  pelvis 
less  flexed.  I  must  admit,  however,  that  I  have  seldom  been  able  to 
make  out  this  feature,  owing  to  the  tenseness  of  the  lower  part  of  the 
uterus.  The  other  feature,  less  resistance  on  the  side  to  which  the 
occiput  is  directed,  is  readily  appreciated. 

Auscultation  may  sometimes  be  of  assistance  in  the  diagnosis,  for 
the  heart  sounds  are  usually  heard  with  difficulty  round  towards  the 


Fig.  12. — Occipito-Posterior  Position  of  Vertex  (3rd  Vertex). 

Hank  to  which  the  back  of  the  child  is  directed,  although  sometimes 
they  are  best  heard  up  towards  the  fundus. 

By  vaginal  examination  the  striking  characteristic  of  occvpito- 
posterior  positions  is  the  ease  icitJt  which  the  anterior  fontanelle  is  felt, 
owing  to  the  fact  that  the  head  is  not  nearly  so  flexed  as  in  the 
ordinary  position  of  the  vertex. 

A  later  chance  of  recognizing  the  position,  and  one  which  should 
never  be  missed,  is  given  when  difficulty  is  experienced  in  extracting 
the  head  at  the  outlet,  for  unless  there  is  deformity  of  the  pelvic 
outlet,  one  never  finds  any  difficulty  in  delivering  with  forceps  a  child 
lying  low  down  with  its  occiput  anterior.  But,  as  if  purposely  arranged 
to  arrest  attention,  yet  another  opportunity  is  afforded  when  traction 
is  made  with  forceps.     Not  only  is  there  difficulty  in  getting  the  head 


28  OPERATIVE  MIDWIFERY 

out,  but  a  peculiar  appearance  of  the  perineum  is  noticeable.  The 
vulvar  orifice  gapes  unusually,  and  the  perineum  begins  to  tear  before 
the  head  has  distended  it. 

In  fully  98  per  cent,  of  the  occipito-posterior  positions  which  have 
been  under  my  care  forward  rotation  of  the  occiput  has  occurred  :  in 
the  other  7  per  cent.,  where  the  occiput  remained  posterior,  the  pro- 
gress of  the  labour  has  usually  been  completely  arrested  or  uterine 
inertia  has  become  established.  Many  French  and  German  observers 
have  found  persistent  occipito-posterior  positions  less  frequent  than 
my  figures  indicate,  a  very  general  figure  given  being  3  or  4  per  cent. 

The  dangers  to  mother  and  child  in  persistent  occipito-posterior 
positions  are  decidedly  greater  than  in  the  ordinary  vertex  position. 
Especially  does  this  apply  to  the  child,  which,  not  infrequently,  is  born 
dead  or  injured ;  indeed,  such  accidents  occur  five  times  as  often  in 
occipito-posterior  as  in  occipitoanterior  positions. 

Lacerations  to  vagina  and  perineum  being  so  common,  the  risks 
to  the  mother  of  infection  are  quite  appreciably  increased;  indeed, 
the  maternal  mortality  is  usually  stated  to  be  about  1  to  1*5  per  cent. 
Croom l  has  called  attention  to  the  occurrence  of  peculiar  deep  longi- 
tudinal lacerations  high  in  the  vagina. 

Treatment. — It  is  recommended  in  occipito-posterior  cases,  recog- 
nized early  in  labour  or  during  pregnancy,  that  the  patient  be  placed 
in  the  knee-elbow  position  or  on  the  side  to  which  the  occiput  is 
directed,  and  that,  with  the  aid  of  manual  manipulations,  the  child's 
back  be  dragged  or  pushed  round  to  the  front.  Although  I  have  not 
been  successful  on  the  few  occasions  upon  which  I  have  tried  such 
manipulations,  without  doubt  they  have  occasionally  proved  successful 
in  the  hands  of  others. 

For  cases  further  advanced  in  labour,  with  the  head  fixed  in  the 
pelvis,  it  is  well  not  to  interfere,  seeing  that  so  few  fail  to  take  a 
favourable  rotation  forward.  This  will  often  necessitate  the  medical 
attendant  allowing  the  second  stage  to  continue  many  hours,  and  it  is 
because  he  does  not  care  to  do  this  that  he  meets  with  so  many  cases 
of  a  persistent  posterior  position. 

When  the  occiput  remains  persistently  posterior  in  spite  of  a  long 
time  given  it  for  rotation,  one  has  the  choice  of  four  methods  of 
treatment :  (1)  Leaving  the  case  to  Nature,  and  still  hoping  for  spon- 
taneous delivery ;  (2)  manual  rotation  and  extraction  with  forceps ; 
(3)  forceps  rotation  and  extraction  ;  (4)  forceps  extraction,  the  occiput 
remaining  posterior. 

Spontaneous  delivery  of  a  persistent  occipito-posterior  presentation 
may  occur  in  one  of  two  ways.     The  head,  either  in  the  region  of  the 

1  Ed.  Obst.  Trans.,  vol.  vi. 


ABNORMAL  PRESENTATIONS  OF  THE  VERTEX         2i> 

anterior  fontanelle  or  of  the  forehead,  is  pressed  against  the  symphysis 
pubis,  while  the  occiput  is  driven  over  the  perineum.  Stumph1  refers 
to  them  as  favourable  and  unfavourable  forms  respectively.  The 
illustrations  (Fig.  13)  explain  themselves.     The  accompanying  outline 


Fig.  13. — Favourable  aud  Unfavourable  Mechanism  of  Birth  in  Persistent  Occipito-Posterior- 
Positions  of  Vertex.     (Stumph.) 

Irawing  (Fig.  14)  of  the  fcetal  head  shows  the  manner  in  which  the 
lead  is  moulded.  But  the  practical  point  is  :  does  this  spontaneous 
lelivery  of  the  head  in  a  persistent  occipito -posterior  position  often 
)ccur  ?  In  my  experience  it  is  very  uncommon.  I  am  prepared, 
lowever,  to  admit  that  this  may  in  part  be  due  to  the  fact  that  I 
nterfere  earlier  than  Continental  operators.  I  have,  however,  in  con- 
sequence, a  lower  fcetal  mortality,  for  while  the  figures  of  those  who 


Fig.  14. — Outline  of  Head  Moulding  in  Persistent  Occipito-Posterior 
Position.     (Spiegel  berg.) 

■re  advocates  of  extreme  expectancy  show  a  mortality  of  10  to  12  per 
ent.,2  mine  are  4  to  5  per  cent. 

To  bring  about  forward  rotation  of  the  occiput  by  manual  interfer- 

nce,  many  devices  have  been  recommended.     Thus,  with  the  object 

Jf  favouring  flexion,  it  has  been  suggested  to  press  up  the  forehead 

uring  a  pain,  pushing  it  at  the  same  time  towards  the  hollow  of  the 

acrum.     Again,  but  directing  attention  to  the  other  end  of  the  fcetal 

1  Winckel's  '  Handbuch,'  1904,  Bd.  i.,  Heffc  2.,  p.  1078. 

2  Hammerschlag;  'Lehrbuch  der  Operativen  Geburtshulfc,'  1910,  p.  407. 


30 


OPERATIVE  MIDWIFERY 


head,  pulling  down  the  occiput  with  the  fingers,  the  vectis,  or  on€ 
blade  of  the  straight  forceps,  has  heen  advocated. 

Sniellie  recommended  a  method  which,  in  recent  years,  was  revivt  d 
by  Tarnier.  One  or  two  ringers  are  passed  into  the  vagina  and 
laid  along  the  side  of  the  child's  head,  and  during  the  uterine  con- 


Fie.  15. — Correction  of  an  Occipito-Posterior  Position  of  Vertex. 

The  internal  hand  rotates  the  occiput  forwards,  while  the  external  drags  round  the 
shoulder  ;  the  arrows  indicate  the  direction  of  these  manoeuvres. 

tractions    the   head   is  pressed    upon   and   rotated   in  the  direction 
desired. 

Doubtless  these  manipulations  have  sometimes  been  successful, 
but,  although  I  have  tried  them  all,  I  have  but  rarely  found  them  so. 
The  only  manoeuvre  I  have  found  of  real  service  is  rotating  the  head 
•by  means  of  the  hand  pressed  into  the  vagina.     The  head  is  grasped 


ABNORMAL  PRESENTATIONS  OF  THE  VERTEX         81 

between  the  fingers  and  thumb  (Fig.  15),  but  before  trying  to  bring 
about  rotation  the  head  must  be  flexed  and  raised  out  of  the  pelvis. 
The  manoeuvre  will  only  succeed,  however,  if  the  other  hand,  applied  to 
the  abdomen  from  the  outside,  brings  the  anterior  shoidder  forward. 
Although  the  fcetal  head  can  stand  very  nearly  a  half-turn,  the  manual 
rotation  of  the  head  alone  is  attended  with  not  a  little  risk  to  the 
child.  Besides,  if  the  shoulder  is  not  brought  forward,  the  head  at 
once  springs  back  into  its  old  position.  It  is  well,  after  having  rotated 
the  head  and  trunk,  to  apply  forceps  and  extract  the  child.  The 
manoeuvre  is  best  carried  out,  I  have  found,  with  the  patient  lying 
upon  her  side.  Taking  my  private  and  hospital  cases  I  have  found 
this  manoeuvre  succeed  in  70  per  cent.,  and  sometimes  even  after 
attempts  had  been  made  to  deliver  the  child  with  forceps. 

Opinions  regarding  the  value  of  manual  rotation  vary.  Speaking 
generally,  the  English  school  may  be  said  to  favour  it,  as  may  be 
seen  from  the  writings  of  such  modern  authors  as  Herman,1  Jardine,2 
and  Eden.3  Stumph,  already  quoted,  gives  it  great  praise,  and  such  is 
the  attitude  of  many  German4  writers.  A  few  French  operators,  follow- 
ing Tarnier's  lead,  approve  of  rotation,  but  many  refer  to  it  as  being 
unnecessary.  Amongst  American  accoucheurs,  it  is  coming  to  be  looked 
upon  with  greater  favour. 

It  may  happen  sometimes  that  if  one  fails  to  bring  about  rotation 
in  the  manner  described,  the  latter  may  be  effected  by  passing  one's 
hand  into  the  uterus  beyond  the  head  and  rotating  the  trunk  by 
directly  pulling  on  the  anterior  shoulder  of  the  foetus.  Quite  recently 
I  was  called  in  consultation  to  a  case  in  which  two  medical  friends 
had  been  making  fruitless  attempts  to  deliver  with  forceps.  Upon 
making  a  vaginal  examination,  I  discovered  that  the  child  was  of  con- 
siderable size,  and  that  the  head,  although  in  the  cavity,  was  placed  with 
the  occiput  posterior.  Under  deep  anaesthesia  I  tried  to  rotate  the 
head  and  body  as  described,  but  failed.  I  then  passed  my  hand  over 
the  side  of  the  child's  head,  seized  hold  of  the  anterior  shoulder,  and 
without  much  difficulty  pushed  it  round.  I  then  delivered  the  child, 
which  weighed  9  pounds,  with  forceps.  It  was  only  slightly 
asphyxiated,  although  a  good  deal  bruised  about  the  head.  Lamond 
Lackie5  has  recorded  a  case  similarly  treated. 

Some  interesting  cases  are  described  by  Von  Weiss0  where,  after 
pushing  up  the  forehead,  the  child  was  delivered  by  expression.     It 

1  '  Difficult  Labour,'  new  edition,  1910,  p.  15. 

2  '  Clinical  Obstetrics,'  3rd  edition,  p.  342. 

3  '  A  Manual  of  Midwifery,'  1906,  p.  223. 

4  Fehling,  '  Die  Operative  Geburtshiilfe,'  1908,  p.  82. 
3  Ed.  Med.  Joum.,  January,  1907.  °  Op.  cit.,  p.  614. 


82 


OPERATIVE  MIDWIFERY 


is  quite  possible  that  this  primitive  method  is  employed  too  seldom 
nowadays,' and  so  it  is  interesting  to  read  of  these  cases  described  by 
Aon  Weiss. 

Rotating  the  head  by  means  of  forceps,  either  straight  or  curved, 
a  method  so  strongly  advocated  by  Tarnier,  Edgar  of  New  York,1  and 
a  few  others,  I  have  seldom  tried,  although  occasionally,  when  extract- 
ing the  child  as  an  occipito-posterior,  I  have  seen  rotation  occur  with- 
out any  attempts  being  made  to  bring  it  about.    As,  however,  we  have 


FlG.    16. — Posterior  Fontanelle  Presentation. 


not  studied  forceps  delivery,  I  will  postpone  until  later  the  consideration 
of  the  employment  of  the  instrument  in  occipito-posterior  positions. 

Anterior  Fontanelle  Presentation.— This  presentation  indicates 
a  diminished  amount  of  flexion.  One  meets  with  it  most  commonly 
in  occipito-posterior  presentations,  which  have  just  been  considered, 
and  in  flat  pelvis  when  the  head  engages  in  the  transverse  diameter  of 
the  brim  with  both  fontanelles  about  the  same  level. 

But  there  is  another  condition  in  which  the  presentation  is 
encountered — occipitoanterior  presentations  —  where,  owing  to  the 
smallness  of  the  head  or  roominess  of  the  pelvis,  the  head  become* 

1  '  Practice  of  Obstetrics,'  1903,  p.  583. 


ABNORMAL  PRESENTATIONS  OE  THE  VERTEX    33 

partly  extended.  As  can  be  readily  understood,  if  that  happens  a 
larger  diameter  of  the  head  is  thrown  across  the  pelvis — indeed,  the 
presentation  approaches  a  brow,  and  the  progress  of  the  labour  becomes 
retarded  in  consequence.  In  a  case  I  saw  some  time  ago  this  was 
-strikingly  illustrated,  and  I  was  compelled,  after  the  second  stage  had 
been  allowed  to  go  on  for  fully  three  hours  without  progress,  to  apply 
forceps.  Even  then  considerable  traction  was  required  to  bring  away 
the  child,  although  the  pelvis  was  quite  normal,  because  the  head  was 
too  small  to  permit  of  the  forceps  getting  a  firm  hold  and  so  main- 
taining flexion.     When  the  child  was  born  it  weighed  only  5  pounds. 


FlG.   17. — Anterior  Parietal  Presentation.     (After  Bumm.) 

Posterior  Fontanelle  Presentation. — This  presentation  (Fig.  16) 
indicates  greatly  increased  flexion,  and  is  brought  about  by  increased 
general  obstruction  to  the  passage  of  the  head.  Thus,  one  meets  with 
it  in  generally  contracted  pelves  and  when  the  head  is  very  large.  The 
labour  is  always  delayed,  and  frequently  instrumental.  The  difficulties 
of  delivery  are  referred  to  under  the  various  operations. 

Anterior  and  Posterior  Parietal  Presentations.  —  It  will  be 
remembered  that  the  head  at  the  brim  not  infrequently  assumes  a 
lateral  or  biparietal  obliquity,  and  comes  to  be  directed  towards  one 
or  other  shoulder.  As  a  result  of  this  the  sagittal  suture,  instead  of 
running  across  the  middle  of  the  pelvis,  comes  to  be  situated  some- 
times nearer  the  symphysis,  sometimes  nearer  the  promontory. 
Occasionally  the  obliquity  becomes  extremely  marked,  and  then  one 


34  OPKUATIYK   MIDWIFERY 

speaks  of  an  anterior  or  posterior  'parietal  presentation'  (Figs.  17 
and  18),  according  as  one  or  other  of  the  parietal  bones  occupies 
the  pelvic  brim.     \>y  the  older  writers  such  presentations  were  termed 

'  ear  presentation-.' 

Prior  to  rupture  of  the  membranes  these  presentations  may 
alternate,  but  after  rupture,  as  the  head  becomes  fixed,  one  or  other 
persists. 

Marked  examples  of  the  malpositions  are  rarely  encountered  when 
the  pelvis  is  of  normal  size,  although,  with  a  pendulous  abdomen, 
before  the  head  is  fixed,  an  anterior  parietal  presentation  often  exists 
if  the  parturient  is  standing  or  lying  on  her  side  and  the  abdominal 


In..   18. — Posterior  Parietal  Presentation.     (After  Bamtn.) 

wall  is  not  supported.  The  condition  therefore  is  pre-eminently  a 
feature  of  flat  pelvis,  and  the  mechanism  of  birth  is  referred  to  in 
connexion  with  that  subject. 

The  variety  of  obliquity  influences  greatly  the  birth,  a  posterior 
parietal  presentation  being  much  less  favourable  than  an  anterior. 
This  is  especially  seen  if  delivery  with  forceps  is  attempted.  "With 
the  anterior  parietal  presentation  traction  brings  the  posterior  parietal 
round  the  sacral  promontory,  while  with  the  posterior  parietal 
presentation  the  anterior  parietal  is  pulled  against  the  symphysis. 
I  have  found  the  anterior  parietal  presentation  more  common  than 
the  posterior  in  the  slighter  degrees  of  pelvic  deformity,  and  the 
reverse  to  be  the  case  where  the  malformation  was  very  decided. 

Engagement  of  the  Head  in  the  Transverse  Diameter  of  the 
Pelvis. — Early  in  labour  one  frequently  finds  the  head  in  this  position, 


ABNORMAL  PRESENTATIONS  OF  THE  VERTEX    35 

even  when  the  pelvis  is  of  normal  capacity.  Usually,  however,  it 
changes  into  the  oblique  before  labour  has  advanced  very  far.  A 
persistent  transverse  position  is  the  rule,  however,  in  flat  pelvis. 

Occasionally,  even  although  the  pelvis  is  normal,  one  meets  with 
a  persistent  transverse  position  if  the  head  is  very  small,  and  more 
than  once  I  have  seen  the  exit  of  the  head  arrested  (Fig.  19)  owing  to 
this  abnormal  position.  It  is,  as  a  rule,  easily  rectified  by  the  hands 
or  by  forceps. 

Engagement  of  the  Head  in  the  Conjugate  Diameter  of  the 
Brim. — I  have  had  no  experience  of  engagement  of  the  head  in  the 
conjugate  diameter,  as  a  cause  of  dystocia.  McKerron1  in  this  country 
has  referred  to  it.    In  his  cases,  however,  there  was  general  contraction 


Fig.   19. — Transverse  Position  of  Vertex  at  Outlet. 

of  the  pelvis,  and  that  appears  to  have  been  the  real  cause  of  the 
arrestment  of  the  head  at  the  brim.  McKerron  states  that  by  rotating 
the  head  into  the  oblique  diameter  he  was  able  to  grasp  it  with  forceps 
and  deliver  easily.  Liepmann's2  paper  is  the  most  recent  that  has 
some  under  my  notice. 

PEESENTATIONS  OF  THE  FACE. 

Facial  presentations  (Fig.  20)  one  is  in  the  habit  of  looking  upon 
is  presentations  of  the  vertex  where,  from  some  cause,  such  as  con- 
racted  pelvis,  obliquity  of  the  uterus,  dolichocephalic  shape  of  head, 
umours  of  the  neck,  etc.,  the  head,  instead  of  remaining  flexed, 
)ecomes  extended.     This  change  of  attitude  in  the  head  occurs,  as 

1  Lond.  Obst.  Trans.,  vol.  xli.,  p.  142. 

2  Zeit.  Gel.  u.  Gnjn.,  Bd.  lxv.,  Heft  2. 


36 


OPK1IATIYE  MIDWIFE!^ 


a  rule,  at  the  commencement  of  labour,  and  the  presentation  resulting 
is  often  spoken  of  as  "  secondary"  presentation  of  the  face, to  distinguish 
it  from  the  "  primary,"  which  may  exist  for  some  time  before  labour. 
Specially  interesting  are  the  cases  described  by  Croom,1  Ahlfeld,2  and 
others,  in  which  the  presentation  has  varied  before  labour,  being 
sometimes  vertex  and  sometimes  face. 

The  diagnosis  of  a  facial  presentation  is  not  always  easy.  By 
careful  palpation  one  searches  for  and  locates  the  head,  the  back,  the 
limbs,  and  the  breech,  just  as  in  positions  of  the  vertex.  But  while  in 
vertex  presentations  this,  as  a  rule,  is  a  simple  matter,  in  presentations 


Fir;.  20.— Third  Position  of  tin-  Face 

of  the  face  considerable  difficulty  may  be  experienced,  owing  to  the 
fact  that  the  abdominal  and  uterine  walls  are  often  more  resistant. 
In  vertex  presentations  we  saw  that  the  back  and  occiput  formed 
a  curved  surface  with  only  a  slight  depression  at  the  neck  :  in  facial 
presentations,  on  the  other  hand,  there  is  a  marked  depression  between 
the  back  and  the  neck,  and  in  conditions  favourable  for  diagnosis, 
as  where  the  child  is  lying  dorso-anterior,  this  depression  can  be 
readily  distinguished.  Not  infrequently,  however,  the  child  lies  with 
its  dorsum  posterior  (Fig.  20),  when  it  is  difficult  to  reach  the  depression 
mentioned.  Some  have  referred  to  the  inferior  border  of  the  chin 
forming  a  horseshoe-like  rim,  which  dips  into  the  cavity  (McLennan), 
and  I  quite  agree  that  this  sometimes  may  be  felt,  but  it  is  only  when 

1  '  Clinical  Papers,'  1901.  2  '  Lchrbuch  der  Geburtshiilfe,'  1898,  p.  387. 


PRESENTATIONS  OF  THE  FACE  37 

the  conditions  are  very  favourable  for  palpation,  as  the  chin  may  easily 
be  mistaken  for  the  prominence  of  the  occiput  and  the  extended  neck 
for  the  flexed  back.  This  leads  me  to  say  that  palpating  the  back  in 
face  cases  is  always  difficult,  because  it  runs  more  down  the  middle  of 
the  uterus,  and  is,  consequently,  out  of  reach. 

As  regards  the  foetal  heart  sounds,  one  often  hears  them  best  high 
up  over  the  chest  of  the  child,  especially  in  mento-anterior  positions. 
Indeed,  in  such  cases,  if  the  uterine  and  abdominal  walls  are  especially 
thin,  the  cardiac  impulse  has  been  felt  occasionally. 

If  a  vaginal  examination  is  hurriedly  made,  the  face  may  be 
mistaken  for  the  vertex,  but  the  presentation  most  frequently  confused 
with  a  face  is  a  breech.  Early  in  labour,  with  the  os  only  slightly 
dilated  and  the  presenting  part  high  up,  I  must  admit  there  is  a 
considerable  difficulty  in  distinguishing  the  two.  Indeed,  it  is  often 
impossible  to  say,  from  vaginal  examination  alone,  which  of  them 
one  has  to  deal  with.  This,  further,  illustrates  the  great  importance 
of  palpation. 

If  the  presenting  face  is  within  reach,  it  will  be  found  that  it  does 
not  so  completely  fill  the  pelvis  at  the  vertex.  It  is  less  hard,  and 
its  outline  is  less  smooth  and  uniform.  The  bony  prominences  of  the 
orbital  ridges,  the  malar  bones,  the  chin,  the  ridge  of  the  nose,  the 
opening  of  the  nares  and  the  alveolar  processes,  can  be  felt,  and  the 
eyes  and  mouth  can  be  distinguished.  But  although,  in  theory,  these 
different  parts  may  help  one  to  a  diagnosis  of  the  presentation,  in 
practice  the  landmarks  that  should  be  relied  on  are  the  alveolar 
processes  and  the  nares.  If  one  trusts  to  other  landmarks  one  will 
certainly  be  led  astray. 

Facial  presentations  occur  about  once  in  200  labours.  In  the 
Glasgow  Maternity  Hospital  in  the  last  ten  years  we  have  found 
facial  presentations  in  the  proportion  of  1  in  200.  Pinard  and  Lepage, 
for  the  Clinique  Baudelocque,  found  them  in  the  proportion  of  1  in  323. 

It  is  not  so  easy  to  decide  the  relative  frequency  of  the  different 
positions,  but  most  authorities  agree  with  Naegele  that  mento-posterior 
positions  are  more  common  that  mento-anterior. 

For  both  mother  and  child  the  prognosis  is  less  favourable  than 
with  vertex  positions.  The  mother's  life  is  placed  in  greater  danger, 
because  of  the  increased  liability  to  lacerations  and  bruises  of  the  soft 
parts,  because  of  there  being  more  vaginal  examinations  and  manipula- 
tions, and,  above  all,  because  the  conditions  which  caused  the  mal- 
attitude  often  still  further  delay  and  complicate  the  labour.  If  delivery 
is  spontaneous,  however,  there  is  no  additional  risk. 

As  regards  the  child,  the  labour  being  generally  delayed,  the  face, 
especially  on  one  side,  becomes  much  swollen,  sometimes,  indeed,  to 


88  ulT.i;\Tl\  i:  MIDWIFERY 

an  alarming  extent.  Then,  again,  vaginal  examinations,  carelessly 
or  excitedly  made,  may  result  in  injuries  to  the  mouth,  nose,  and 
especially  the  eyes,  while,  as  the  result  of  the  great  extension  of  the 
head  (Fig.  21),  injuries  to  the  soft  parts  of  the  neck  occasionally  occur, 
especially  if  forceps  is  employed. 

In  69  cases  of  face  presentation  in  the  Clinique  Baudelocque 
from  LS90  to  1!)00  there  were  no  maternal  deaths  ;  in  52  the 
temperature  was  normal  throughout,  in  17  it  was  slightly  raised  ; 
62  women  were  spontaneously  delivered  ;  in  1  the  face  was  converted 
into  a  head  presentation  ;  in  -1  primipara-  2  were  delivered  by  forceps 
and  2  by  symphysiotomy  ;  in  1  multipara,  perforation  (dead  child)  ; 
in  1  multipara,  forceps  (with  fracture  of  the  child's  skull).  Palotai,1 
for  Kczmarszky's  Clinique,  Budapest,  analyzing  108  cases,  gives  the 
following  figures  :  In  50  to  00  per  cent,  the  totus  had  originally  lain 
in  the  first  position  ;   duration  of  labour  averaged  fifty-two  minutes 


Fig.  21. — Outline  of  Attitude  and  Moulding  of  Head  in  Face  Presentations. 

(Spiegelberg.) 

more  than  in  head  presentations  ;  operative  measures  were  required 
in  only  4*85  per  cent,  of  cases  :  maternal  mortality.  0  per  cent. :  fatal 
mortality,  8' 10  per  cent.  The  author  therefore  believes  that  face 
presentations  should  be  treated  expectantly.  Our  results  at  the 
Glasgow  Maternity  Hospital  have  been  very  much  worse.  This, 
in  great  part,  is  due  to  early  interference,  which  is  undoubtedly  a 
mistake,  but  also  to  the  fact  that  so  many  cases  are  admitted  to  the 
hospital  after  attempts  at  delivery  have  been  made  outside. 

Treatment.  —  This  presentation  being  less  favourable  to  the 
mother  and  child  than  that  of  the  vertex,  the  first  question  to  be 
considered  is  whether  or  not  one  should  convert  it  into  the  latter. 
Before  taking  up  that  important  question,  however,  a  word  about 
another  line  of  treatment  that  has  been  advocated  by  some — viz.,  the 
performance  of  version  and  bringing  down  the  feet.  Personally,  I  do 
not  favour  this  in  uncomplicated  face  presentations,  because  the  total 

1  Qyruekologia,  1902,  No.  1,  Ref.  Joiu-n.  Obst.  and  Qyn.  Brit.  Empire,  vol.  iv., 
p.  313. 


PRESENTATIONS  OF  THE  FACE  39 

mortality  is  greater  when  the  head  comes  last.  Only  if  there  is  some 
condition  such  as  pelvic  deformity,  placenta  previa,  prolapse  of  cord, 
or  some  danger  threatening  the  mother,  calling  for  immediate 
delivery,  would  I  have  recourse  to  version. 

The  first  to  describe  clearly  manipulations  for  the  conversion  of 
face  presentations  was  Baudelocque.1  There  are  two  methods  to  which 
Baudelocque's  name  is  attached,  and  they  are  generally  referred  to  as 
I.  and  II.  In  Method  I.  that  great  obstetrician  recommended  the 
pushing  up  of  the  face  with  the  fingers  in  the  vagina,  while  the  other 
hand  from  the  outside  pressed  down  the  occiput.  In  Method  II.  he 
recommended  the  passing  of  the  hand  into  the  uterus  and  the  pulling 
down  of  the  occiput.  Now,  anyone  who  has  tried  either  of  these 
methods  will  have  found  that,  while  a  face  can  often  be  changed  into 
a  vertex,  the  old  presentation  usually  returns  whenever  the  hands  are 
removed.  This  is  chiefly  because  the  lordosis  associated  with  a  facial 
presentation  remains,  not  being  removed  by  the  alteration  in  the 
attitude  of  the  head.  The  results  from  Baudelocque's  manipulations 
have  therefore  been  disappointing. 

Some  thirty-five  years  ago  Schatz2made  a  most  important  con- 
tribution to  the  subject  by  describing  certain  manipulations  directed 
to  altering  the  lordosis,  and  which  were  carried  out  externally.  To 
carry  out  Schatz's  manipulations,  the  operator  faces  the  patient,  and, 
having  palpated  out  the  anterior  shoulder  and  the  breech,  he  raises 
the  shoulder  and  back  of  the  child.  He  then  applies  three  fingers  of 
the  hand,  that  is  raising  the  shoulder,  against  the  chest,  while  with 
the  other  hand  he  pushes  the  breech  in  the  opposite  direction.  With 
the  hand  over  the  breech,  he  then  presses  the  child  downwards.  As 
can  be  imagined,  considerable  manipulative  dexterity,  mobility  of  the 
foetus  in  utero,  and  relaxation  of  the  abdominal  walls,  are  necessary 
before  one  can  even  hope  to  carry  out  the  treatment  successfully. 
Personally,  I  have  always  failed,  and  the  experience  of  accoucheurs  in 
this  and  other  countries  has  been  equally  or  nearly  as  unfavourable. 

It  was  very  soon  seen  that  a  combination  of  the  methods  of 
Baudelocque  and  Schatz  would  be  more  efficacious  than  either,  and 
so  several  operators  suggested  this.  Thorn3  probably  deserves  the 
greatest  credit  for  perfecting  the  combined  method  of  internal  and 
external  manipulations  now  favoured  (Fig.  22).  For  the  internal 
manipulations,  Thorn  favours  Baudelocque  I. — that  is,  pressing  the 
face,  then  the  forehead,  upwards.  Baudelocque  II. — the  pulling  down 
of  the  occiput  with  the  hand  or  fingers  introduced  into  the  uterus — 
may  also  be  employed  ;  but  Thorn  does  not  consider  this  so  safe.    The 

1  Heath's  translation,  1790,  vol.  ii.,  p.  229.  2  Arcliiv  f.  Gyn.,  Bd.  v. 

■'  Zeit.  f.  Gel.  u.  Gyn.,  Bd.  xiii.,  1886,  and  Bd.  xxxi.,  Heft  1.,  p.  1,  189S. 


40 


OPERATIVE  MimVII'KllY 


external  hand  of  the  operator  presses  against  the  protruding  chest  in 
the  direction  indicated  in  the  illustration.  An  assistant,  when  avail- 
able, then  drags  the  breech  over  in  the  opposite  direction. 

The  internal  manuaivres  may  be  varied  slightly.     For  example, 


Fig.  22. — Thorn's  Method  for  converting  a  Face  into  a  Vertex  Position. 
The  arrows  indicate  the  directions  of  pressure  and  traction. 

the  head  may  be  grasped  antero-posteriorly  by  the  thumb  and  fingers, 
as  Opitz  recommends,  but  one  need  not  detail  all  the  trifling  varia- 
tions which  have  been  suggested.  To  employ,  however,  the  internal 
hand  for  correcting  the  lordosis  by  passing  it  into  the  uterus  and 


PRESENTATIONS  OF  THE  FACE  41 

pressing  upon  the  chest  is  undesirable  and  sometimes  dangerous. 
Besides,  it  is  usually  unsuccessful,  for,  if  it  is  necessary,  the  uterus  is 
too  firmly  applied  to  the  surface  of  the  child.  If  an  assistant  is  not 
available  for  dragging  over  the  breech,  the  breech  may  fall  over  itself 
by  placing  the  patient  upon  the  opposite  side  to  which  it  is  directed. 
In  the  Glasgow  Maternity  Hospital  during  the  years  1896  to  1906 
the  manipulations  described  were  successful  in  about  65  per  cent, 
of  the  cases.  For  the  Berlin  University  '  Frauenklinik  '  Olshausen 
states  that  from  the  years  1886  to  1900  they  had  114  cases,  with  79 
successes — 70  per  cent.1  Weiss2  and  Thorn3  give  their  successes 
as  50  per  cent,  and  75  per  cent,  respectively. 

Having  corrected  the  mal-attitude  of  head  and  body,  the  foetal 
head  should  be  pushed  firmly  down  into  the  pelvis,  and  a  pad  and 
binder  applied,  or  immediate  delivery  effected  with  forceps. 

For  the  employment  of  the  manoeuvres  described,  it  is  of  the 
greatest  importance  that  the  patient  should  be  deeply  anesthetized, 
the  cercix  /cell  dilated,  the  uterine  walls  not  applied  too  closely  to 
the  surface  of  the  child,  and  the  head  not  too  firmly  imparted  in  the 
-pelvis.  Consequently,  they  must  be  carried  out,  as  a  rule,  com- 
paratively early  in  labour,  although  occasionally  I  have  seen  them 
successful  even  when  labour  was  far  advanced.  When  attempts 
are  made  late  in  labour,  the  head  must  be  dislodged  from  the 
pelvis,  and  that  usually,  by  pushing  the  child  against  the  uterus, 
stimulates  the  uterus  to  contract  firmly,  and  prevents  the  external 
manoeuvres  from  being  carried  out.  Besides,  the  head  at  this  stage 
is  much  moulded,  and  so  does  not  readily  adapt  itself  to  a  new 
position  in  the  pelvis. 

Judgment  regarding  the  different  methods  of  treatment  in  face 
presentations  must  be  based  on  the  foetal  mortality,  for  the  maternal 
mortality  in  hospital  practice  and  in  the  hands  of  careful  obstetricians 
has  been  reduced  to  a  minimum. 

Failure  to  convert  a  face  into  a  vertex  presentation  is  of  little 
moment,  for  very  good  results  are  obtained — in  fact,  many  say  better 
results — when  one  leaves  the  labour  to  Nature. 

It  is  entirely  the  attitude  of  the  partisan  for  Thorn  and  others  to 
explain  away  the  good  results  obtained  by  purely  expectant  treatment, 
such  as  those  given  by  Boer  and  Zeller — 120  cases  with  only  six  foetal 
deaths,  a  mortality  of  only  5  per  cent. — and  those  recently  given  by 
Hammerschlag,4  with  a  foetal  mortality  of  only  6  per  cent.  (89  per  cent. 

1  '  Lehrbuch  der  Geburtshiilfe,'  Olshausen  and  Yeit,  5th  edition,  1902,  p.  210. 

2  Volkmann's  Klin.  Vortrdge,  No.  74,  1893. 

3  Ibid.,  No.  339,  1902. 

4  '  Lehrbuch  der  Operativen  Geburtshilfe,'  1910,  p.  408. 


42  OPERATIVE  MIDWIFERY 

of  the  cases  were  treated  expectantly).  The  best  results,  after 
correction,  are  those  of  Opitz  Iot  Olshausen's  Klinik — 8*9  per  cent. 
mortality. 

As  far  as  can  be  judged  at  present,  the  best  results  are  obtained 
by  judicious  expectancy.  It  appears  to  me,  therefore,  that  the 
routine  practice  of  correcting  face  presentations  is  not  called  for. 
I  am  quite  prepared  to  admit  that  it  is  often  successful,  especially 


FlG.  23. — Persistent  Mento-Postf  rior  Position  ol  Faoo. 

when  Thorn's  method  is  employed,  but  some  experience  and  practice  is 
required  before  the  requisite  amount  of  manual  dexterity  is  obtained. 
In  the  meantime,  therefore,  I  would  advise  the  general  practitioner 
to  leave  face  presentations  alone.  If,  however,  he  is  anxious  to  try  the 
method  described,  and  he  can  choose  his  time,  he  will  get  the  best 
results  by  operating  when  the  os  uteri  is  about  three-quarters  dilated, 
and  when,  in  introducing  his  hand  into  the  uterus,  he  requires  to 
rupture  the  membranes. 


PRESENTATIONS  OF  THE  FACE  43 

But  there  is  another  matter  which  must  be  considered.  What  is 
;o  be  done  with  those  cases  which  one  treats  expectantly  or  fails  to 
jonvert,  and  in  which  the  chin  remains  directed  posteriorly  (Fig.  23)  ? 
[n  such  cases  it  has  been  possible  occasionally  to  dislodge  the  head 
md  convert  the  presentation  into  a  vertex,  or,  by  manipulations, 
similar  to  those  described  for  occipito  -  posterior  positions  of  the 
/ertex,  to  bring  the  chin  to  the  front.  With  a  face  firmly  impacted 
n  the  pelvis,  those  manoeuvres  have,  as  a  rule,  failed.  It  is  usually 
;aught  that  there  is  then  nothing  left  but  to  perforate,  but  we 
nave  had  one  or  two  cases  where,  with  axis-traction  forceps  and  by 
simply  exerting  traction,  rotation  of  the  chin  has  occurred.  Lewers,1 
i  few  years  ago,  gave  an  interesting  description  of  two  such  cases, 
tnd  others  have  been  recorded  at  odd  times.  Reed's2  paper  on  this 
subject  is  most  valuable ;  seventy-five  recorded  cases,  beginning  with 
me  by  Smellie,  are  analyzed.  It  is  very  interesting,  for  the  results 
lave  not  been  nearly  so  bad  as  is  generally  indicated  in  textbooks. 
Here  are  some  of  Reed's  conclusions  : 

'  Rotation. — Manual  succeeds,  4  (Yolland,  1)  ;  fails,  9  (Yolland,  4)  ; 
orceps  succeeds,  25  (33  per  cent.) ;  fails,  16  (21  per  cent.). 

'Manual  Flexion. — Fails,  5  cases  (Thorn,  1)  ;  succeeds,  12  (16  per 
:ent.).  Vectis  succeeded  in  2  of  the  3  cases  tried.  Version  tried  in 
rain  in  4  cases. 

'Delivery.  —  Unrotated,  17;  spontaneous  after  correction,  10. 
forceps  succeeded,  28  (37  per  cent.)  ;  failed,  3 ;  axis  traction, 
forceps  succeeded,  3 ;  failed,  0 ;  craniotomy,  14. 

'  Mortality. — Mother  :  Live,  61 ;  die,  8 ;  not  stated,  6.  Babies  : 
jive,  39;  die,  30;  not  stated,  6.' 

It  is  evident,  therefore,  that  attempts  at  rotation,  and  even 
tttempts  at  delivery,  with  forceps  are  quite  justifiable,  and  frequently 
uccessful  even  in  the  most  hopeless  cases  of  mento-posterior  posi- 
ions  of  the  face. 

BROW  PRESENTATIONS. 

I  must  now  say  a  word  or  two  about  the  most  unfavourable  of  all 
lead  presentations — viz.,  the  brow  (Fig.  24),  the  attitude  between 
vertex  and  face.  Fortunately,  this  unfavourable  attitude  is  very  rare, 
or  it  occurs  only  in  about  1  in  2,000  cases. 

As  regards  etiology,  the  position  may  be  looked  upon  as  a  variety 
>f  face  presentation,  for  the  same  factors  influence  the  occurrence  in 
»oth.  When  one  has  said  that,  however,  the  resemblance  ceases.  A 
•row  is  an  infinitely  more  unfavourable  presentation  than  a  face. 

1  Lond.  Obst.  Trans.,  1899,  vol.  xli.,  p.  280. 

2  Amer.  Journ.  Obst.,  1905,  vol.  li.,  p.  615. 


1! 


OPERATIVE  MII>\Vlll.l;\ 


The  diagnosis  of  the  presentation  is  rarely  made  until  the  os 
is  sufficiently  dilated  to  permit  one  feeling  such  landmarks  as  the 
anterior  fontanelle,  and  especially  the  supra-orhital  ridges.  True,  if 
conditions  are  very  favourable,  one  may  make  out  by  abdominal 
palpation  the  chin  and  the  head  less  flexed  than  usual,  but  the  deep 
depression  between  the  occiput  and  the  back,  which  can  often  be 
appreciated  in  face  presentations,  is  not  so  marked.  Even  vaginal 
examination  may  leave  one  in  doubt  if  the  membranes  have  been  long 
ruptured  and  a  caput  succedaneum  has  formed.  Besides,  the  head  is 
often  high  in  the  pelvis,  for  it  engages  in  the  occipito-mental  diameter, 


FlG.  24. — Brow  Presentation. 

the  longest  cranial  diameter,  and  so  finds  great  difficulty  in  entering  the 
pelvis.  Should  there  be  any  doubt  about  the  presentation,  the  patient 
should  be  anaesthetized  and  a  thorough  examination  made. 

In  certain  cases  one  may  be  deceived  as  regards  the  extent  to 
which  the  head  has  descended,  for  the  caput  and  elongated  forehead 
may  give  the  impression  that  the  head  is  lower  than  it  really  is. 

Spontaneous  delivery  in  brow  presentations  rarely  occurs,  except 
when  the  child  is  below  and  the  pelvis  above  the  normal.  When  it 
does  occur,  the  face  in  the  region  of  the  base  of  the  nose  is  fixed 
against  the  pubes,  and  the  anterior  fontanelle  and  rest  of  the  head 
sweep  over  the  perineum.  If  the  chin  remains  posterior,  spontaneous 
deliver}7  is  impossible.  The  moulding  of  the  head  is  shown  in  the 
illustration  (Fig.  25). 


BROW  PRESENTATIONS  45 

As  already  stated,  the  prognosis  for  both  mother  and  child  is  by 
no  means  good,  although,  since  rectification  has  become  more  general, 
the  results  for  both  have  greatly  improved.  All  manner  of  injuries 
to  the  mother  are  liable  to  occur,  and  Von  Franque  states  that  rupture 
of  the  uterus  occurs  in  3  per  cent,  of  cases.  In  one  brow  presentation 
brought  into  the  Maternity  Hospital  the  uterus  was  ruptured.  Tears 
of  the  perineum,  fistulas  in  bowel  and  bladder,  have  frequently  resulted. 
The  long  duration  of  the  labour,  and  the  injuries  to  the  brain  and  soft 
part  about  the  face,  especially  if  the  child  is  dragged  through  with 
forceps,  account  for  the  high  foetal  mortality. 

Brow  presentations,  therefore,  cannot  be  treated  expectantly,  which 
many  still  consider  the  right  course  to  pursue  with  face  presentations. 


Fig.  25. — Two  Forms  of  Moulding  which  the  Head  may  undergo  in  Brow  Presentations. 

(Spiegelberg.) 

Nor  should  they  be  treated  with  forceps  and  the  child  dragged  through 
the  pelvis,  for  such  a  procedure  is  attended  with  great  risk  to  both 
the  child  and  the  mother. 

Version  or  rectification  of  the  position  are  the  only  alternative 
treatments.  Personally,  I  favour  version  when  the  presentation  is 
recognized  early,  for,  although  the  fcetal  mortality  is  smaller  after 
rectification,  there  is  probably  20  to  30  per  cent,  in  which  rectification 
fails,  and  this,  should  it  happen,  is  a  very  serious  matter  in  brow 
presentations. 

When  labour  has  advanced  and  version  is  consequently  unsuitable, 
rectification  after  the  manner  of  Thorn,  already  described  in  connexion 
with  face  presentations,  should  be  practised. 

A  year  or  two  ago  a  woman,  whose  child  presented  by  the  brow, 
was  admitted  to  the  Glasgow  Maternity  Hospital  advanced  in  labour. 


16  OPKIIATIVH   MIDWII'i:i;V 

Several  fruitless  attempts  at  delivery  with  forceps  had  been  made  before 
she  was  sent  to  the  hospital.  My  assistant  rectilied  the  mal-attitude, 
and  without  much  difficulty  delivered  a  living  child  weighing  12  pound.-. 
We  have  had  three  other  such  cases  in  recent  years,  and  all  have  been] 
successful.  As  regards  the  cases  delivered  by  forceps,  in  one  the  child 
was  alive,  in  the  other  it  was  dead. 

The  recent  results  from  rectification  have  been  very  satisfactory. 
Von  Franijiic1  for  342  collected  cases  gives  the  following  : 

Version      ...        ...  ...  57  cases— 33*3  per  cent,  dead  children. 

Forceps        ...  77      ,,       27  „  ,, 

Alteration  into  a  face  ...  14      ,,       14  ,,  ,, 

„       vertex  ...  43      „         7  „  „ 

When  an  alteration  into  a  face  or  vertex  fails,  and  the  conditions 
are  unfavourable  for  version,  it  has  been  recommended  that  sym- 
physiotomy should  be  performed.  Wallich,  for  the  Clinique  Baude- 
locque,  for  several  such  cases  gives  a  maternal  mortality  of  5  per  cent, 
and  a  foetal  of  28  per  cent.  I  have  once  performed  the  operation  for 
this  condition.  Both  mother  and  child  recovered  and  left  the  hospital 
well.  I  believe  it  is  rarely  indicated,  and  only  if  rectification  fails 
and  the  child  is  in  a  thoroughly  satisfactory  condition.  As  a  last 
resort,  craniotomy  is  the  only  treatment. 

PROLAPSE  OF  LIMBS  ASSOCIATED  WITH  PRESENTATION 
OF  THE  HEAD. 

Prolapse  of  an  arm  is  a  common  occurrence  in  oblique  presenta- 
tions. With  head  presentations  (Fig.  26),  however,  it  is  very  rare,  a& 
it  happens  only  about  once  in  400  cases. 

Naturally,  any  condition  which  hinders  the  engagement  of  the 
head  predisposes  to  the  accident.  Thus,  contracted  pelvis,  pelvic 
tumours,  hydramnios,  and  sudden  rupture  of  the  membranes,  are  the 
most  common  causes  on  the  side  of  the  mother  ;  while  prematurity, 
maceration,  and  abnormal  positions  of  the  head,  such  as  those  of  the 
face,  brow,  and  occipito-posterior  positions  of  the  vertex,  may  be  men- 
tioned in  connexion  with  the  f(etus. 

The  arm,  of  course,  prolapses  much  more  readily  than  the  foot, 
and  generally  it  is  the  anterior  arm.  Some  extraordinary  cases  have 
been  recorded  where  both  arms  and  legs  have  presented.  Broom2 
has  related  a  very  interesting  one  where  the  head  and  two  feet  became 
arrested  at  the  brim.  Yon  Zumph  describes  one  where  there  was  pro- 
lapse of  both  feet  and  arms  and  the  cord  in  a  facial  presentation.  Hall3 
describes  a  very  complicated  condition  where  the  head  was  impacted 

1  Winckel's  '  Handbuch,'  Bd.  ii.,  Teil  iii.,  1905,  p.  1582. 

2  Lancet,  1890,  p.  1298.  3  Archiv  f.  Qyr    *H  lxiii.,  1901. 


PROLAPSE  OF  LIMBS  47 

between  the  legs  of  the  child,  and  many  odd  and  interesting  cases  are 

to  be  found  scattered  throughout  the  literature  relative  to  the  subject. 

When  the  foot  or  feet  come  down,  the  child  is  invariably  premature 

or  macerated,  and  the  uterus  is  firmly  retracted  over  the  child's  trunk. 


Fig.  26.— Prolapse  of  Ann  in  Vertex  Presentations.     (Bumm.) 

I  have  only  once  experienced  difficulty  in  diagnosing  the  condition — 
when  a  foot  came  down  beside  the  head  and  the  tips  of  the  toes  felt 
exactly  like  the  prolapsed  cord. 

A  careful  examination  under  an  anaesthetic  should  always  be  made 
in  doubtful  cases,  when  it  will  invariably  clear  matters  up. 


48 


0PERAT1\  i:   MIDWII'I.KV 


I'pon  three  occasions  I  have  found  the  hand  preventing  the  child's 
head  engaging  at  the  brim,  but  the  arm  was  easily  displaced,  and  tin- 
head  immediately  entered  and  descended. 

Naturally,  considerable  difficulty  may  be  experienced  in  delivering 
the  child  if  the  prolapsed  limb  is  not  recognized,  especially  if  the 
pelvis  is  deformed,  and  that  accounts  for  the  fact  that  not  infrequently 
the  mother  and  child  have  been  seriously  injured.  The  fu-tal  mor- 
tality, however,  is  also  increased  by  the  fact  that  the  children  are 
often  premature  and  badly  nourished. 

In  simple  prolapse  of  the  arm  the  latter  can  invariably  be  pushed 
up,  and  that  should  always  be  the  treatment  followed.     To  look  upon 


Fig.  '11- — Dorsal  Displacement  of  the  Arm. 

Hie  condition  as  an  oblique  presentation  and  perform  version  is  a 
mistake.  When  a  foot  comes  down,  however,  especially  if  the  uterus 
is  very  firmly  retracted  over  the  child,  there  may  sometimes  be  not 
.a  little  difficulty  in  pushing  the  limb  up.  Here  again  version  is  a 
mistake,  and  it  is  usually  very  difficult.  The  course  to  pursue  is  to 
•deeply  anaesthetize  the  patient  and  push  up  the  leg. 

A  peculiar  but  very  rare  displacement  of  the  arm  is  the  dorsal 
displacement  (Fig.  27),  which  was  first  described  by  Sir  J.  Y.  Simpson 
to  the  Edinburgh  Obstetrical  Society  in  1850. l  Since  then  many 
cases  have  been  recorded.  Sir  A.  R.  Simpson  in  1879-  reviewed 
those  recorded  to  date.  Barbour3  in  1887  recorded  a  case  in  which, 
after  the  birth  of  the  head,  in  spite  of  extreme  traction,  the  child 


1  •  Collected  Works,'  vol.  i.,  p.  381. 

2  Trans.  Ed.  Obst.  Soc,  Session  1878-1879,  vol. 

3  Eilin.  Med.  Joum.,  September,  1817,  p.  216. 


p.  97. 


PROLAPSE  OF  LIMBS  49 

could  not  be  delivered.  Finally,  an  arm  was  pulled  down,  and 
then  it  was  discovered  that  the  other  was  behind  the  occiput.  It, 
too,  was  delivered  with  difficulty,  and  during  the  process  was  fractured. 
Wells1  recently  recorded  an  interesting  case. 

In  most  cases — Simpson's,  for  example — the  head  is  prevented  from 
descending,  but  in  others  the  difficulty  may  only  occur  after  the  head 
has  been  delivered.  Apparently  the  arm  catches  upon  the  retraction 
ring,  although  it  may  sometimes  be  on  the  pelvic  brim. 

Naturally,  the  condition  is  easily  overlooked.  It  should,  however, 
be  suspected  if  there  is  difficulty  in  delivering  the  head  or  shoulders 
when  the  pelvis  is  of  normal  capacity,  the  foetus  of  normal  size  and 
in  the  ordinary  position.  By  passing  the  hand  up  beyond  the  pre- 
senting part,  the  bent  arm  is  felt. 

Replacement  often  succeeds,  but  is  sometimes  accomplished  with 
great  difficulty,  so  much  so  that  version  is  recommended  by  several 
writers.  With  deep  anaesthesia  in  the  Sims  position,  however,  I  should 
imagine  that  reposition  of  the  arm  could  usually  be  accomplished. 

1  Lancet,  January  19,  1907,  p.  165. 


CHAPTEli  V 
DYSTOCIA  THE  RESULT  OF  FAULTS  IN  THE  FCETUS— Continued 

Breech  Presentations. 

Pelvic  presentations,  as  everyone  is  aware,  are  much  less  favourable 
than  those  of  the  vertex.  The  maternal  mortality  and  morbidity  Lfl 
greater  because  of  the  more  frequent  vaginal  examinations  and  manipu- 
lations, while  the  foetal  mortality  is  somewhere  between  15  and  20  per 
cent.  Many  of  the  foetal  deaths  are  unavoidable,  but  a  great  number  are 
quite  preventable,  and  are  purely  the  result  of  unwise  management. 
In  detailing  the  treatment  of  the  presentation  and  its  varieties  I  have 
deemed  it  advisable  to  consider  the  subject  in  some  detail. 

Diagnosis. — The  diagnosis  of  a  breech  presentation  by  abdominal 
palpation  is  not  always  easy.  Undoubtedly  in  many  cases  one  can 
feel  the  breech  at  the  pelvic  brim,  and  recognize  it  as  being  softer 
and  less  globular  than  the  head,  and  immobile  apart  from  the  trunk  ; 
while  at  the  fundus  of  the  uterus  the  hard  globular  head  is  often 
distinguishable.  Still,  in  many  cases  these  features  are  not  easy  of 
recognition.  The  most  characteristic  feature,  when  it  is  present,  is 
the  '  ballotting '  of  the  head  between  the  two  hands  placed  on  each 
side  of  the  fundus.  Such  symptoms  as  undue  fulness  of  the  fundus 
uteri,  and  tenderness  to  pressure  over  that  part,  are  not  characteristic, 
and  may  be  present  in  cranial  presentations. 

By  vaginal  examination  early  in  labour  it  is  often  impossible  to 
determine  the  presenting  part,  as  it  is  generally  difficult  to  reach  it. 
Later,  when  the  os  is  dilated,  and  the  soft,  irregular  breech  can  be 
distinguished,  one  feels  two  bony  prominences  with  a  depression 
between  them,  and  sometimes  the  genitalia  of  the  child.  But  the 
most  important  landmark  is  the  spinous  processes  of  the  sacral 
vertebrae.  Still  later,  and  after  the  membranes  have  ruptured,  these 
landmarks  are  even  more  distinct — the  anus  can  be  felt,  and  is 
distinguishable  from  the  mouth  by  the  absence  of  the  alveolar 
processes.  In  addition,  as  the  child  descends  and  its  abdomen  is 
compressed,  meconium  is  forced  out,  and  escapes  from  the  maternal 
passage  with  each  uterine  contraction. 

50 


BREECH  PRESENTATIONS  51 

THE  BREECH  ARRESTED  AT  THE  PELVIC  BRIM. 

An  actual  failure  of  the  breech  to  engage  and  descend  is  observed 
•when  there  is  distinct  disproportion  between  the  maternal  canal  and 
the  lower  part  of  the  trunk  of  the  child.  On  the  maternal  side  may 
be  mentioned  such  conditions  as  deformity  of  the  bony  pelvis,  and 
tumours  of  the  uterus  or  surrounding  structures ;  while  on  the  foetal 
side  the  most  important  are  unusual  size  of  the  child's  pelvis,  and 
tumours  of  its  pelvis  and  abdomen. 

The  maternal  abnormalities  referred  to  are  not  difficult  of  recog- 
nition— at  least,  pelvic  deformity,  if  at  all  pronounced,  should  not  be 
overlooked.  In  cases  of  contracted  pelvis,  when  the  deformity  of  the 
pelvis  is  only  slight  or  moderate,  most  authorities  recommend  bring- 
ing down  a  leg  in  breech  cases,  and  probably  for  ordinary  practice 
that  procedure  is  the  best.  It  is,  however,  quite  possible  in  many 
cases,  as  I  have  proved,  to  perform  bipolar  cephalic  version,  and 
bring  the  head  to  present.  One  is  then  able  to  accurately  estimate 
the  relative  size  of  the  foetal  head  and  maternal  pelvis.  I  refer  to 
this  again  at  the  end  of  the  chapter. 

Tumours,  ovarian  or  uterine,  are  easily  overlooked,  especially  if 
they  are  of  medium  size,  for  bimanual  palpation  of  them  is  not 
always  possible,  owing  to  the  presence  of  the  distended  uterus. 
Recently  I  had  personal  experience  of  this  in  a  case  of  an  ovarian 
cyst  which  was  only  distinguishable  when  the  presenting  part  of  the 
■child  was  pushed  out  of  the  pelvis. 

With  foetal  abnormalities,  such  as  a  sacral  tumour  or  enormous 
distension  of  the  foetal  abdomen,  the  diagnosis  is  always  difficult. 
They  can  often  only  be  appreciated  by  a  process  of  exclusion  and  by 
introducing  the  whole  hand  into  the  uterus. 

Besides  the  conditions  referred  to,  the  engagement  of  the  pre- 
senting part  may  be  interfered  with  by  alterations  in  the  axis  of  the 
canal,  such  as  are  produced  by  a  pendulous  abdomen,  or  as  a  result 
of  the  operation  of  vaginal  or  abdominal  fixation  of  the  uterus 
(Chapter  XIX.). 

But  in  addition  to  such  abnormalities  in  mother  or  foetus,  it  is 
frequently  necessary  to  bring  dowm  one  or  both  feet  for  dangers 
threatening  the  life  of  the  mother  or  child.  In  this  connexion,  on 
the  mother's  side,  such  conditions  as  placenta  prsevia,  severe 
eclampsia,  phthisis  pulmonalis,  or  cardiac  disease,  and  on  the  child's 
prolapse  of  the  cord  may  be  mentioned. 


52  OPKUATIYK   MinWIFKl^ 


WRINGING   DOWN   A   FOOT. 

Although  it  is  comparatively  easy  to  bring  down  a  foot  when  the 
breech  is  arrested  at  the  brim,  and  is  indicated  under  certain  circum- 
stances, it  must  not  be  forgotten  that  the  risks  to  the  mother  and 
child  are  decidedly  increased,  especially  if  forcible  extraction  of 
the  child  follows.  Traction,  therefore,  should  only  be  exerted  and 
delivery  completed  if  there  is  distinct  danger  to  the  mother  in  delay, 
for  if  the  breech  is  forcibly  drawn  upon,  not  only  do  the  arms  become 
extended,  but  the  cervix,  being  insufficiently  dilated,  grasps  the  after- 
coming  head  with  a  force  impossible  to  overcome,  unless  deep  incisions 
are  made  in  the  cervix.  In  other  conditions,  such  as  placenta  praevia, 
contracted  pelvis,  or  large  child,  the  case  should  be  left  to  Nature 
until  the  whole  breech  is  born.  By  so  doing  the  maternal  mortality 
will  be  reduced  to  a  minimum,  and  the  fu'tal  mortality  will  be  kept  at 
the  lowest  possible  figure. 

Before  giving  details  as  to  how  the  operation  should  be  performed, 
I  must  answer  the  question,  Is  it  ever  an  advantage  to  bring  down 
both  feet  ?  The  only  circumstance,  in  my  experience,  under  which  it 
has  appeared  to  have  been  an  advantage  was  when  rapid  emptying 
of  the  uterus  was  deemed  necessary.  Often  it  is  not  easy  to  get  hold 
of  both  feet.  Besides,  it  increases  the  fcetal  mortality  ;  consequently, 
it  is  only  when  rapid  delivery  for  the  sake  of  the  mother  is  the  first 
consideration,  and  the  life  of  the  child  is  of  only  secondary  conse- 
quence, that  both  feet  should  be  brought  down. 

The  bringing  down  of  a  foot  is  seldom  a  difficult  manuuvre ;  but 
occasionally,  and  especially  if  the  membranes  have  ruptured  early  and 
the  breech  is  fixed,  it  may  give  rise  to  a  good  deal  of  trouble.  Until 
comparatively  recent  years  the  recommendation  was  to  seize  both  legs, 
or  whichever  one  presented  ;  but  now  the  advice  of  all  writers,  with- 
out exception,  is  to  bring  down  the  one  directed  anteriorly.  In  this 
country  we  are  largely  indebted  to  Barnes  for  having  clearly  pointed 
out  the  advantage  of  such  a  procedure.  By  looking  at  the  illustration 
(Fig.  28),  it  will  be  at  once  apparent  why  the  anterior  is  better  than 
the  posterior.  With  the  posterior  leg  down,  the  anterior  buttock 
catches  on  the  symphysis  pubis,  and  the  descent  of  the  foetal  pelvis  is 
arrested.  Even  if  traction  is  made  on  the  limb  matters  are  only  made 
worse,  for  it  is  impossible  to  get  the  line  of  traction  in  the  axis  of  the 
pelvis.  But  it  is  not  always  easy  to  get  hold  of  the  anterior  leg,  and 
it  is  especially  difficult  if  the  abdomen  is  pendulous,  if  the  liquor 
amnii  has  drained  away,  or  if  the  pelvis  is  contracted.  Besides,  the 
legs  are  often  crossed,  and  confusion  in  consequence  arises. 

Be  the  cause  what  it  may,  how  is  the  unfavourable  position  to  be 


BREECH  PRESENTATIONS 


53 


overcome  ?  To  push  the  limb  back  and  seize  the  other  is  usually 
impracticable,  even  if  it  were  worthy  of  consideration,  while  the 
bringing  down  of  the  other  limb  is  not  always  possible.  One  is 
■compelled  in   these  cases,  therefore,  to  make  the  best    of   matters. 


Flu.  28. — The  posterior  leg  has  been  brought  down,  with  the  result  that  the  anterior 
buttock  catches  upon  the  symphysis  pubis.  The  arrows  indicate  the  rotations  of  the 
trunk  which  result  when  traction  is  made  on  the  leg. 


Now,  if  such  a  case  is  left  to  Nature,  it  will  be  seen  that  the 
posterior  thigh  comes  to  the  front  and  becomes  anterior  by  rotation. 
In  doing  this,  however,  it  is  apparent  that  the  trunk  may  take  either 
■a  long  or  a    short  rotation    (Fig.  28 — the  arrows  indicate  the  two 


:,1  OPERATIVE   MIDWIIT.IIY 

varieties).  Most  modern  writers  seem  agreed  that  the  long  rotation  is 
the  more  general.  Here  is  the  opinion  of  two  who  have  given  tin 
suhject  special  consideration.  Faraboeuf  and  Varnier1  write:  '  La 
rotation  abandoning  a  la  spontaneity  se  fait  toujour 8  par  le  eheniin 
le  plus  long':  while  Nagel 2  says:  'Die  Drehung  des  Rumpfes  um 
seine  Langsachse  geschieht  desshalb  auf  dem  langeren  Wege,'  etc. 

As  a  rule,  however,  if  the  posterior  Leg  is  pulled  upon,  the  foetal 
pelvis  takes  the  long  rotation  in  a  dorso-anterior  and  the  short  in 
a  dorso-posterior  position.  Occasionally  a  short  rotation  occurs  even 
in  dorso-anterior  positions,  according  to  Faraboeuf;  but  that  is  the 
exception,  and  certainly  I  have  rarely  seen  it  happen.  Rotation  may 
be  greatly  helped  by  the  hand  grasping  the  buttock  between  the 
thumb  and  finger,  and  encouraging  the  particular  rotation  the  breech 
is  tending  to  take. 

In  carrying  out  the  manipulation  of  bringing  down  a  foot,  the 
hand,  with  the  fingers  brought  together  in  the  form  of  a  cone,  is 
carefully  insinuated  into  the  uterus,  through  vulva,  vagina,  and 
cervix.  I  need  not  say  that  this  must  be  done  after  the  patient's 
genitalia  and  the  operator's  hands  have  been  thoroughly  cleansed. 
No  hard-and-fast  rule  can  be  laid  down  as  regards  the  hand  to  be 
employed  and  the  position  of  the  patient,  for  matters  of  that  kind 
must  be  left  to  the  judgment  and  experience  of  the  operator.  This 
only  I  would  say,  that  the  prospective  obstetrician  should  train  him- 
self to  be  ambidextrous.  Personally,  I  prefer,  when  bringing  down  a 
foot,  to  have  the  patient  upon  her  back,  and  I  employ  the  hand  which, 
introduced  into  the  uterus,  will  most  readily  and  most  comfortably 
reach  the  limbs.  Consequently,  if  the  limbs  are  towards  the  mother's 
right  side,  I  employ  my  left  hand,  and  if  they  are  to  her  left  side,  my 
right. 

Many,  especially  in  this  country,  prefer  the  patient  in  the  left 
lateral  position,  and,  as  I  shall  show,  this  is  sometimes  a  distinct 
advantage.  If  such  a  position  is  employed,  it  will  usually  be  found 
that  the  left  hand  is  most  suitable  when  the  limbs  are  to  the  back, 
and  the  right  when  they  are  directed  to  the  front  of  the  mother. 
The  cases  in  which  it  is  a  distinct  advantage  to  have  the  patient 
in  the  left  lateral  position,  and  even  to  raise  the  pelvis  with  a  pillow, 
are  those  difficult  cases  where  the  breech  is  impacted  in  the  maternal 
pelvis  (p.  80).  Under  such  circumstances  the  lateral  position  allows 
the  force  of  gravity  to  come  into  play,  and  so  favours  the  dislodge- 
ment  of  the  foetal  pelvis,  especially  if  in  addition  the  patient  is  deeply 
anaesthetized. 

1  'Introduction  des  Accout-hemcnts,'  1904,  p.  165. 

2  'Operative  Geburtshulfe,'  1902,  p.  42. 


BREECH  PRESENTATIONS  55 

Probably  all  operators — at  least  all  English  operators  of  any 
experience — have  appreciated  the  advantage  of  the  left  lateral  position 
in  those  conditions  described  where  there  is  great  difficulty  in  dis- 
lodging the  fu'tal  pelvis.     Barnes  speaks  highly  of  it,  Nagel  does  the 


FlG.  29. — The  operator  has  passed  his  hand  along  the  ventral  aspect  of  the  child,  and 
is  seizing  the  anterior  leg.     (Nagel.) 


same,  while  the  older  obstetricians  in  the  days  before  anaesthetics  often 
made  use  of  the  position,  or  even  the  genu-pectoral  position  ;  see,  for 
example,  the  recommendation  of  Smellie.1 

Having  introduced  the  hand  into  the  uterus,  it  should  be  passed 

1  Smellie's  '  Midwifery,'  McClintock,  vol.  i.,  p.  317. 


50 


nl'KKATIYK  MIDWII-'KUY 


along  the  ventral  aspect  of  the  child,  over  the  thigh  and  lower  part 
of  the  leg  to  the  foot  (Fig.  2!)),  which  is  to  he  grasped  hetween  the 
lingers.  It  the  legs  are  hent  upon  themselves,  the  foot  is  en- 
countered almost  whenever  the  hand  is  introduced  ;  but  if  the  legs 
are   extended   along   the  trunk,  the  hand  will  require  to  be  passed 


Fig.  30. — Pinard's  Manoeuvre  for  bringing  the  Foot  within  Reach. 


almost  to  the  fundus  before  the  foot  can  be  seized.  The  manipula- 
tions must  only  be  carried  out  in  the  intervals  between  the  uterine 
contractions.  During  the  pains  the  hand  must  lie  passive  against  the 
child's  body. 

Pinard  has  suggested  a  manoeuvre — no  doubt  employed  from  time 
immemorial,  for  one  sees  it  hinted  at   in    the  writings   of   the   old 


BREECH  PRESENTATIONS  57 

•obstetricians — for  bringing  the  foot  more  readily  within  reach.  As 
seen  from  the  illustration  (Fig.  30),  the  fore  and  middle  ringers  are 
applied  over  the  thigh  and  press  the  latter  against  the  trunk,  with 
the  result  that  the  foot  is  brought  lower,  and  can  be  more  readily 
seized  ;  at  the  same  time  the  external  hand  presses  down  the  trunk. 
It  is  seldom  of  use,  however,  when  the  uterus  is  firmly  applied  to  the 
child's  body  or  the  legs  extended.  Usually  the  lower  leg  can  be 
readily  bent  on  the  thigh,  but  when  one  comes  to  draw  down  the 
thigh  the  knee  catches  on  the  uterine  wall.  In  such  cases  the  breech 
must  be  dislodged  and  pushed  up,  while  the  trunk  is  pulled  over  by 
the  external  hand  applied  over  the  fundus  ;  indeed,  for  a  moment  the 
j  presentation  is  actually  made  oblique. 

IThe  hand  which  is  inside  the  uterus,  and  which,  as  I  have  already 
stated,  is  only  moved  during  the  intervals  between  the  contractions, 
should,  when  possible,  observe  the  character  of  the  foetal  pulsations  in 
the  cord,  for  the  condition  of  the  fcetal  pulse  naturally  influences  the 
further  treatment.  The  operator,  however,  must  not  be  surprised  by 
a  very  decidedly  intermittent  and  rapid  pulse  after  any  disturbance  of 
the  child,  for  this  is  the  rule  ;  but  it  is  only  temporary,  it  soon  quietens 
down  after  the  manipulations  cease,  provided  the  condition  of  the 
child  is  satisfactory. 

Extraction  of  the  Child  by  Traction  on  the  Leg. — Having 
considered  the  indications  for,  and  the  methods  of,  bringing  down 
a  foot,  and  the  advantage  of  bringing  down  the  anterior  one,  we  must 
proceed  to  the  manner  of  extracting  the  child.  Before  doing  so,  I 
would  once  again  warn  my  readers  against  such  a  proceeding  with 
the  os  undilated,  unless  the  indications  are  most  pressing.  It  is  no 
exaggeration  to  say  that  the  risks  to  the  mother  are  doubled,  and  those 
to  the  child  trebled  or  quadrupled,  by  such  a  step.  It  is  sometimes 
necessary,  however,  although  almost  the  only  indications  are  dangers 
threatening  the  life  of  the  mother,  when  it  is  imperative  that  the  uterus 
should  be  evacuated  as  quickly  as  possible.  It  might  be  thought  that 
danger  threatening  the  life  of  the  child  would  also  be  a  reason,  but,  as 
a  matter  of  fact,  in  practice,  that  is  only  the  case  if  the  os  is  fully 
dilated.  No  fcetus,  showing  cardiac  embarrassment,  could  be  ex- 
tracted alive  unless  the  parturient  canal  was,  at  the  commencement 
of  the  operation,  sufficiently  dilated  to  allow  of  the  child  passing,  or 
unless  the  operator  was  prepared  to  make  deep  incisions  in  the 
servix. 

The  foot  is  to  be  grasped  in  the  manner  shown  (Fig.  31),  and  if 
traction  is  made  upon  both  feet  they  are  best  held  with  one  finger 
between,  to  prevent  them  chafing.  The  attachment  of  a  fillet  is  seldom 
necessary.     The  line   of   traction   should   be  well  back,  so  as  to  be 


58 


OPERATH  E  MIDWIFERY 


exerted  as  nearly  as  possible  in  the  a\i.s  of  the  brim.  ( )nce  t  be  knee  is 
born,  the  operator's  hand  should  be  passed  over  the  thigh  so  that  the 
latter  rests  in  his  fingers,  while  his  thumb  is  applied  over  it-  dorsal 
aspect  (Fig.  ;{'2).  When  the  posterior  buttock  distends  the  pelvic  fl  >or, 
the  leg  on  which  the  traction  is  being  made  should  be  pulled  upward-. 
I!   need  be  a  finger  may  be  passed  into  the  fold  of  the  other  thigh,  so- 


<\ 


Fig.  31. — The  Manner  of  grasping  the  Foot. 

that  a  little  more  traction  can  be  exerted  (Fig.  83).  There  should, 
however,  be  no  attempt  at  pulling  down  the  leg,  which  is  still  along 
the  side  of  the  trunk,  until  the  foetal  pelvis  is  completely  born.  Then 
it  can  be  dislodged  by  passing  the  lingers  up  to  the  bend  of  the  knee, 
and  sweeping  the  lower  part  of  the  leg  over  the  lower  part  of  the 
trunk. 

All  this  time  delivery  of  the  breech  may  be  much  facilitated  by 


BREECH  PRESENTATIONS 


5!r< 


a  nurse  or  assistant  exercising  pressure  on  the  uterus.  This,  however, 
must  be  done  during  the  uterine  contractions ;  it  is  profitless  to  apply 
it  in  the  intervals. 

Both  legs  being  now  down,  traction  on  the  trunk  should  be  carried 
out  by  applying  the  thumbs  over  the  dorsal  aspect  of  the  fatal  pelvis, 


FlG.  32.— The  Manner  of  grasping  the  Leg  when  Traction  is  being  made  upon  it.     (Nagel.) 


and  the  fingers  over  the  ventral  surface  of  the  thighs  (Fig.  34).  The 
3hild  should  on  no  account  be  grasped  round  the  abdomen.  While 
axerting  traction  at  this  stage  the  accoucheur  must  see  that  the  cord 
is  not  dragged  upon ;  a  loop  should  therefore  be  pulled  down. 

So  far  the  delivery  is  seldom  troublesome,  but  the  fact  of  having 
had  to  exert  traction  renders  the  rest  of  the  operation,  the  disengage- 


<;o 


nl'KIIATIVE  MIJ>\\  1 1  KkY 


ment  of  the  arms  and  head,  a  matter  of  considerable  difficulty,  for  in 
a  large  proportion  of  cases  they  will  be  extended.  Jt  is  just  at  this 
stage  that  quick  delivery  of  the  child  is  so  important.  Hough  l_v 
speaking,  once  the  child  is  born  as  far  as  the  umbilicus  it  will  nol 
survive  if  longer  than  eight  minutes  is  taken  for  its  extraction.  I  >f 
•course,  in  many  cases,  as  we  have  seen,  where  the  delivery  is  hastened,? 


Fis.  33. — The  Forefinger  of  the  Left  Hand  passed  into  the  Groin/ Is  order  to  help  the 
Delivery  of  the  Breech.     (Nagel.) 


the  child's  life  hardly  comes  into  consideration,  as  the  operation  is 
performed  in  the  mother's  interests. 

In  forcibly  extracting  a  child  by  the  feet  the  difficulty  in  bringing 
down  the  arms  and  head  is  frequently  increased  by  the  fact  that  the 
cervix,  not  being  completely  dilated,  firmly  grasps  the  body  underneath 
the  arms  (Fig.  85).  In  such  a  condition,  with  a  large  child,  unless 
■one  is  prepared  to  forcibly  dilate  and  tear  the  cervix,  or  to  make 


BPE E CH  PRE S E N T ATION S 


(\1 


deep  incisions  into  it,  there  is  little   chance  of  delivering  a  living 
child,  and  the  hope  of  doing  so  should  be  abandoned. 

The  necessity  for  bringing  down  the  arms,  prior  to  extracting  the. 


FlG.  34. — The  Maimer  of  Grasping  the  Breech  when  Traction  has  to  be  exerted  upon  it. 

head,  has  only  been  universally  taught  and  practised  since  Baude- 
(ocque's  time.  Prior  to  that  date  some  recommended  leaving  the  arms 
alone,  as  Deventer;  others  bringing  down  one,  as  Pare.  Mauriceau,. 
iiowever,  recommended  bringing  down  both,  while   Smellie  advised 


62 


OPERATIVE  MIDWIFERY 


bringing  down  the  arm  only  if  the  pelvis  was  small  and  the  child 
large. 

In  disengaging  the  arms  it  is  always  an  advantage  to  first  bring 
down  the  one  which  is  directed  posteriorly,  for  there  is  more  room  for 
carrying  out  the  manipulations  in  the  hollow  of  the  sacrum. 

In  order  to  bring  the  arm  well  within  reach,  the  child  should  be 
pulled  up  towards  the  abdomen  of  the  mother  and  a  little  to  one  or 


Fig.  35.— Showing  the  Upper  Pan  of  the  Trunk  caught  by  a  Cervix  not  fully  dilated. 

(Attn-  1'iuilin  and  Tarnier.) 


other  side — if  the  back  is  to  the  right,  to  the  left;  if  the  back  is  to 
the  left,  to  the  right  (Fig.  30).  With  a  heavy  child  this  is  rather 
irksome,  and  so  may  be  delegated  to  an  assistant.  The  operator, 
however,  usually  finds  it  a  distinct  advantage  to  perform  the  manoeuvre 
himself. 

A  mistake  which  is  very  commonly  made,  and  one  which  renders 
the  disengagement  of  the  arms  much  more  difficult,  is  pulling  the 
trunk  of  the  child  too  far  down,  for  it  has  the  effect  of  impacting  the 


BREECH  PRESENTATIONS 


68 


head  and  arms  in  the  pelvis.  Generally  speaking,  when  one  feels  the 
lower  angle  of  the  anterior  scapula  just  about  the  level  of  the  lower 
margin  of  the  symphysis  pubis,  one  should  proceed  to  bring  down  the 
aims.  Indeed,  in  contracted  pelvis,  and  with  a  very  large  child,  it 
will  sometimes  be  advantageous  to  do  so  earlier. 


Fig.  36. — Bringing  down  the  Posterior  Ann.     (Nagel. 


The  hand  to  be  employed  is  the  one  which  can  be  passed  most  con- 
veniently along  the  back  of  the  child,  so  that  while  one  hand  is  pulling 
the  child  forward  the  other  is  insinuated  into  the  vagina  and  carried 
up  the  spinal  column.  If  the  child's  arm  is  within  easy  reach,  two 
angers  inserted  into  the  vagina  and  the  thumb  over  the  child's  back 
[F  ig.  36)  is  sufficient,  but  at  other  times  the  whole  hand  must  be  inserted. 
Having  come  to  the  shoulders,  two  fingers  should  be  carried,  or  rather 


CI 


OPEEATIVB  MIDWIFERY 


laid,  along  the  upper  arm  as  far  us  the  bend  of  the  elbow,  and  t In- 
arm pulled  or  pushed  down  over  the  child's  face.     One  must  never  try 


Fig.  37. — Bringing  down  the  Anterior  Ann  withonl  rotating  the  Trunk. 


to  bring  the  arm  down  by  simply  getting  one  or  two  fingers  beyond 
the  shoulder  and  pulling  on  the  humerus,  for  that  will  almost  certainly 


BREECH  PRESENTATIONS  65 

result  in  its  fracture.  If  the  arm  cannot  be  reached,  the  trunk  should 
be  disengaged  a  little  by  pushing  it  up,  and  the  whole  hand,  except 
the  thumb,  should  be  passed  along  the  upper  arm. 

Having  brought  down  the  posterior  arm,  one  has  the  choice  of 
bringing  down  the  other,  keeping  it  anterior  or  rotating  the  trunk  until 
it  becomes  posterior.  The  former  manoeuvre,  most  favoured  by  the 
French,  is  often  quite  possible,  and,  if  so,  should  be  adopted.  It  is 
carried  out  by  pulling  the  child  in  a  backward  direction  (Fig.  37)  and 
passing  the  ringers  over  the  shoulder  on  to  the  arm,  as  has  just  been 
described  in  connexion  with  the  posterior  arm. 

But  it  is  sometimes  impossible  to  bring  down  the  anterior  arm  in 
that  way.  In  such  cases  the  trunk  should  be  rotated,  and  the  arm 
which  was  anterior  carried  round  until  it  comes  to  be  posterior. 
Some  operators,  indeed,  make  a  practice  of  always  employing 
this  latter  method.  But  rotation,  although  usually  carried  out  quite 
easily,  is  not  altogether  free  from  risk,  for  if  the  chin  is  low  and 
catches,  the  head  is  arrested,  and  torsion  of  the  neck,  beyond  the 
point  of  safety,  follows.  When  carrying  out  rotation,  therefore, 
the  trunk,  grasped  by  the  two  hands  with  the  thumbs  placed  over 
the  back  and  the  fingers  round  the  body  (Fig.  38),  should  be  pushed 
up,  and  the  head  and  remaining  arm  dislodged  from  the  pelvis  ; 
then,  alternately  rotating  and  pushing  up  the  trunk,  the  latter 
is  gradually  brought  round  to  the  position  which  renders  the  arm 
accessible  from  the  hollow  of  the  sacrum. 

Rotation,  however,  may  be  made  in  the  direction  of  either  the  black 
or  the  dotted  arrow.  If  one  makes  it  in  the  direction  of  the  dotted  arrow, 
the  anterior  arm  comes  posterior,  and  the  head  remains  to  be  extracted 
occiput  anterior,  the  best  position  for  extracting  the  after-coming  head. 
It  seems,  therefore,  the  most  natural  course,  and,  as  a  matter  of  fact, 
is  the  one  generally  recommended.  It  has,  however,  sometimes  a 
distinct  disadvantage,  for  in  the  process  of  rotation,  the  arm,  becoming 
arrested  by  the  friction  against  the  uterine  wall,  comes  to  take  up  a 
position  more  or  less  behind  the  occiput.  It  has  always  seemed  to 
me,  therefore,  better  to  follow  the  direction  of  the  black  arrow. 

In  the  particular  position  under  consideration,  the  rotation  must 
lot    be   stopped   when    the    shoulder   reaches   the   right    sacro-iliac 
■ynchondrosis,  otherwise,  although  the  arm  could  be  brought  do'jvj 
me  would  have  to  deal  with  an  occipito-posterior  position  of  the  af 
oming  head.     Rotation,  therefore,  must  be  continued  still  furthe. 
,nd  the  shoulder  be  carried  to  the  other  sacro-iliac  synchondrosi  g 
•efore  the  arm  is  brought  down,  for  by  so  doing  one  will  obtain  whatl 
3  desired,  an  occipitoanterior  position  of  the  head.     But  this  long 
otation  will  be  found  of  great  advantage  in  another  respect.     All  the 


c.ti 


OPERATIVE  MlDWII'Km 


time  the  arm  tends  to  come  more  over  the  face,  and  the  last  si 
of  rotation  aids  this  more  than  ;ill  the  rest,  for  the  iirin  catches  on 
the  projecting  spinal  column  and  becomes  very  accessible.     Eaving 
placed  the  arm  posterior,  it  is  brought  down  as  already  described. 

Rotation  may  be  aided  by  seizing  the  arm  which  is  already  down, 
and  dragging  or  pushing  the  trunk  by  means  of  it  (Fig.  39),  but  such 


Fig.  38. — Bringing  down  the  Second  Arm.     (Nagel.) 

The  posterior  arm  having  been  brought  down,  the  operator  is  rotating  the  trunk 

to  bring  the  anterior  arm  into  the  hollow  of  the  sacrum,  where   it   can    be  eaailj 
reached.     The  dark  arrow  is  the  right  direction  of  rotation. 

a  manoeuvre  is  not  advisable,  and  the  manipulations  already  described 
a/^  the  best. 

It  sometimes  happens,  owing  to  the  large  size  of  the  child  or  the 
,arrowness  of  the  bony  canal,  that  there  is  extreme  difficulty  in 
wringing  down  the  arms.  In  such  cases,  under  anaesthesia,  the  trunk 
of  the  child  should  be  pushed  well  up,  the  hand  passed  along  the 
ventral  aspect  of  the  child,  and  the  anterior  arm  brought  down.  If 
such  extreme  difficulty  is  anticipated,  it  is  well  to  do  as  Kiistner  has 


BKEECH  PKESENTATIONS 


07 


suggested,    and    bring    down   an    arm   immediately  after   the   navel 
appears. 

When,  after  many  and  futile  attempts,  the  arms  cannot  be  brought 
down,  a  blunt  hook  must  be  used.  I  have  only  had  to  do  this  with  a  dead 
child  where  the  maternal  passage  was  deformed  and  the  child  was  of 


Fig.  39. — Rotation  of  the  Trunk  by  pulling  or  pushing  the  Trunk  with  the  Ann  already 
brought  down — a  Manoeuvre  not  recommended. 


extreme  size.  If  recourse  is  had  to  a  hook,  it  should  be  passed  along 
the  dorsal  aspect  of  the  child,  over  the  elbow,  and  the  arm  pulled 
upon — it  is  invariably  fractured.  I  have  sometimes  required  to  use 
i  sharp  hook  for  such  cases. 


68  OPERATIVE  MIDWIFERY 

Occasionally  it   has   even   been  necessary  to  perforate   the   head 
before  bringing  the  arm  down. 

Sometimes  one  of  the  arms  gets  displaced  behind  the  occiput — 


Fig.  40. — Dorsal  Displacement  of  the  Arm,  and  the  Manner  in  which  the  Trunk  should 
be  rotatcrl  in  Order  to  briny  the  Arm  into  the  Hollow  of  t  he  Sacrum,  and  .so  wit  bin 
Easy  Rcai-li. 

'dorsal'  or  '  nuchal '  displacement  of  the  arm.  It  has  even  happened 
that  both  have  become  so  displaced — a  malposition  often  extremely 
difficult  to  rectify.     It  is  a  matter  of  simplicity   in  the  case  where, 


BKEECH  PRESENTATIONS  69. 

one  arm  being  already  clown,  the  other  is  discovered  behind  the 
neck  (Fig.  40),  for  a  simple  rotation  of  the  body  in  the  direction 
of  the  arrow  will  result  in  the  arm  becoming  arrested  and  the 
head  slipping  past  the  arm.  Should,  however,  both  arms  be  still 
alongside  of  the  head,  they  must  be  brought  down  by  the  operator 
passing  his  whole  hand  into  the  uterus  after  the  trunk  of  the  child 
has  been  pushed  up  and  disengaged,  or  they  must  be  brought  within 
reach  by  rotation.  If  rotation  is  chosen,  it  is  at  once  evident  that, 
as  the  trunk  is  rotated  and  the  one  displaced  arm  corrected,  the 
malposition  of  the  other  is  aggravated.  The  trunk  is  therefore 
rotated — the  direction  here  does  not  matter — and  the  posterior  arm, 
which  is  more  easily  reached,  disengaged;  then  the  child  is  rotated 
back  again  to  allow  of  the  other  arm  being  brought  down. 

In  cases  where  the  child's  abdomen  is  forward  at  the  stage  when 
the  arms  have  to  be  disengaged — a  condition  which  need  never  occur 
if  one  favours  rotation  of  the  back  forward  as  the  breech  is  being  born 
— some  obstetricians  recommend  pulling  the  child  backwards  and 
passing  the  hand  up  along  its  ventral  aspect,  and  disengaging  the 
arms  from  that  side  ;  while  others  favour  approaching  the  arms  from 
the  dorsal  aspect.  It  is  impossible  to  detail  all  the  little  nianceuvres 
fvhich  have  been  suggested.  Fritsch's,  however,  seems  good.  It 
consists  in  passing  one  hand  over  the  front  of  the  child's  shoulders, 
ind  then  pushing  its  trunk  upwards  with  the  other,  the  arms  being 
;hus  dislodged  by  the  movement  of  the  trunk  rather  than  by  any 
lirect  manipulation  on  the  arms. 

EXTRACTION  OF  THE  HEAD. 

Having  delivered  the  arms,  the  operator  now  proceeds  to  the 
xtraction  of  the  head.  Should  he  have  already  lost  much  time 
n  bringing  down  the  arms,  it  is  of  the  greatest  importance,  if  the 
hild  is  to  be  born  alive,  that  he  extracts  the  head  quickly.  But  while 
hat  is  fully  appreciated  by  everyone,  it  is  often  forgotten  that  many 
hildren  are  lost,  not  so  much  by  delay  as  by  undue  and  misdirected 
faction  on  the  trunk,  causing  fracture  and  dislocation  of  the  upper 
art  of  the  spinal  column.  It  is  a  matter  of  extreme  difficulty  to  give 
le  relative  proportion  of  cases  lost  by  delay  and  those  lost  by  injury 
d  the  spinal  column,  but  I  feel  convinced  that  a  much  larger 
umber  of  cases  are  lost  by  the  latter  than  is  generally  supposed.  So 
npressed  am  I  with  this  that  it  has  become  my  practice  in  the 
ist  few  years  always  to  deliver  the  after-coming  head  with  forceps 
?ig.  41),  if  moderate  traction  and  suprapubic  pressure,  in  the  manner 
)  be  described,  fail  to  effect  the  delivery.     Consequently,  I  always 


70 


OPERATIVE  MIDWIFERY 


have  forceps  ready  at  hand  in  a  breech  presentation,  or  when  I  have 
brought  down  a  foot ;  not  that  I  often  employ  the  instrument,  for  thai 
is  seldom  necessary,  but  I  prefer  to  have  it  ready  in  case  it  should  be 
required.  Since  I  have  had  recourse  to  forceps  in  all  cases  of  the 
least  difficulty,  my  results  have  been  infinitely  Fetter. 

This,  it  may  be  said,  is  a  very  prominent  position  for  forceps  to 


Fig.  11. — The  Delivery  of  the  After-coming  Head  with  Forceps. 

occupy  in  the  treatment  of  the  after-coming  head,  and  many,  I  know, 
will  not  agree  with  me,  especially  those  who  follow  Continental 
teaching.  Most  English  obstetricians  of  experience  will  side  with  me, 
however,  for  the  treatment  has  always  been  in  favour  in  this  country, 
since  our  great  Smellie  recommended  it.  Barnes1  wrote  of  it :  '  It  is 
1  'Obstetric  Operations,'  p.  171. 


BREECH  PRESENTATIONS  71 

to  be  preferred  to  manual  traction,  because  it  avoids  pulling  upon 
the  cervical  articulations  ';  and  again  (p.  57)  :  '  But  if  there  be  any 
delay,  the  forceps  will  be  safer  for  the  child.  The  forceps,  then,  is 
the  more  scientific  instrument.1  Herman 1  says :  '  This  is  the  best 
waj'  of  delivering  it  (the  head)  when  help  is  needed.' 

Obstetricians  of  other  countries,  taken  as  a  whole,  are  either 
lukewarm  or  directly  opposed  to  the  employment  of  forceps.  Zweifel,2 
for  example,  admits  that  the  instrument  is  easy  of  application,  but  is 
opposed  to  its  employment  because  it  takes  time,  and  because  the 
results  of  forceps  delivery  are  bad,  and  he  quotes  the  statistics  of 
Sickel.3  But  no  time  is  lost  if  the  forceps  are  ready  to  hand,  as  I 
have  recommended  they  should  be  ;  and  it  is  not  to  the  point  to  quote 
statistics  of  cases  in  which  forceps  were  only  had  recourse  to  after 
many  futile  attempts  at  manual  extraction.  How  can  one  expect  good 
results  with  forceps  in  such  cases?  Williams4  takes  up  a  more  pro- 
nouncedly antagonistic  attitude,  and  writes :  '  As  a  matter  of  fact,  it 
is  never  necessary  to  resort  to  the  forceps  under  such  conditions.' 

There  are  indications,  however,  in  quite  recent  years  that  the 
employment  of  forceps  for  the  delivery  of  the  aftercoming  head  is 
being  looked  upon  with  more  favour.  In  both  of  two  recent  and  most 
excellent  German  works  on  operative  midwifery — I  refer  to  those  by 
Skutch  and  Nagel — and  in  Edgar's  large  text-book  forceps  is  very 
favourably  referred  to,  while  in  the  recent  and  very  important 
German  work — Winckel's  '  Handbuch  der  Geburtshiilfe  ' — Wyder 
considers  the  subject  very  fairly,  and  although  he  does  not  advocate 
forceps  so  strongly  as  I  have  done,  he  writes  favourably  of  the 
employment  of  the  instrument.  The  only  cases  in  which  I 
believe  forceps  unwarrantable  are  those  in  which  the  maternal 
pelvis  is  too  small  or  the  fcetal  head  hydrocephalic.  I  would  place 
the  lowest  limit  as  a  conjugata  vera  of  3^  inches  (8'7  centimetres). 

But,  as  I  have  already  said,  although  always  having  forceps 
ready  for  use,  I  seldom  require  to  employ  them.  Like  most  modern 
obstetricians,  I  believe  that  the  best  of  the  many  methods  of  extract- 
ing the  after-coming  head  is  the  method  now  generally  associated 
with  the  names  of  Mauriceau,5  Smellie,  and  Yeit. 

1  '  Difficult  Labour,'  5th  edition,  1910,  p.  57. 

2  '  Lehrbuch  dor  Geburtshiilfe,'  1892,  p.  705. 

3  Schmidt's  '  Jahrbucher,'  Bd.  lxxxviii.,  p.  112. 
1  '  Obstetrics,'  1910,  p.  419. 

5  'Traite  des  Maladies  des  Femmes  grosses,"  4th  edition,  1694,  p.  284. 

The  following  brief  summary  of  the  various  methods  which  have  been  from 
time  to  time  suggested  for  dealing  with  the  after-coming  head  may  be  of  interest 
(Winckel's  'Lehrbuch,'  translated  by  Edgar,  1890,  p.  687)  : 

'  The  methods  to  deliver  the  after-coming  head  as  rapidly  and  safely  as  possible 


72  OPERATIVE   MlhWII  KKY 

Mauriceau1  waa  the  first  to  lay  down  clearly  instructions  as  to  how 
the  arms  and  after-coming  head  should  lie  delivered.  Smellie-  Beeme 
to  have  been  quite  unaware  of  them,  for  he  does  not  refer  to  Mauriceau 
in  his  writings  on  the  subject.  Veit,  who  perfected  the  manoeuvre 
and  described  it  most  carefully,  certainly  deserves  to  have  his  name 
associated  with  the  method. 

The  illustration  (Fig.  42)  indicates  how  the  manoeuvre  is  carried 
out.  One  linger  of  the  right  or  left  hand — whichever  can  most  con- 
veniently be  employed — is  introduced  into  the  mouth  ;  over  the  arm  of 
this  hand  the  child  rides.    By  this  means  the  head  is  maintained  in  an 

are  very  old,  and  have  been  often  modified  and  combined  in  many  ways.  An 
historical  retrospect  is  at  this  point  especially  interesting.  We  find  the  following 
methods  : 

'  1.  Both  hands  are  introduced,  and  with  them  the  head  only  is  grasped  and 
retracted. — Hippocrates  :  "  De  Superfoetatione,"  Basel,  1546;  ed.  Cornarius,  p.  66. 

'  2.  The  severed  head  is  pressed  from  without  into  the  pelvis  with  both  hands, 
and  extracted  from  the  vagina  with  hooks. — Celsus  :  Liber  VII.,  491. 

'3.  The  severed  head  is  extracted  with  a  finger  introduced  into  the  mouth 
and  one  or  more  hooks. — Paulus  .Egenita  :  "  De  Foetus  Imuiortui  Extractione  et 
Exsectione,"  cap.  74. 

'  4.  Traction  on  the  body,  sternutation  of  the  parturient,  and  light  compression 
of  the  lower  portion  of  the  abdomen. — Abulcasis :  Liber  II.,  "Exitus  Embryonia 
super  Pedes  suas";  Jacob  Rueff,  1580  (Hebammenbuch,  s.  74 1. 

'  5.  Traction  from  the  mouth  on  the  lower  jaw  and  the  shoulders. — Mauriceau  : 
"  Traite  des  Maladies  des  Femmes  grosses,"  Paris,  1668 ;  Marguerite  de  la  Marche, 
1677;  Paul  Portal,  1685;  Chapman,  1735;  Levret,  1747:  Boederer,  1759;  Prange, 
1760;  Fries,  1769;  Baudelocque,  1781;  Stark,  1801;  Lachapelle,  1821;  G.  Veit, 
1863.     Modification  by  Stein,  17S3  ;  Steidele,  1784. 

'6.  Traction  on  the  lower  jaw  and  the  feet. — Peu  :  "Pratique  des  Aeeouch.," 
Paris,  1694. 

'  7.  Traction  on  the  lower  jaw  and  on  the  shoulders  and  the  feet  by  an  assistant. 
—  Mauriceau  :  "  Traite  des  Maladies  des  Femmes  grosses,"  dernierc  edition, 
Paris,  1683;  Dionis,  1718;  Puzos,  1759;  Lachapelle,  1821  ("Pratique,"  etc., 
pp.  334,  335);  Ahlfeld,  1875,  Arc/Uv  ./'.  Gyn.,  viii.  360  (1887);  "  Ber.  u.  Arb.  ana 
Marburg,"  1887,  p.  150. 

'8.  Traction  on  the  upper  jaw  internally  and  pressure  on  the  head  externally 
— L.  Heister,  171s. 

'9.  Traction  on  the  lower  jaw  and  pressure  against  the  occiput  internally. 
De  la  Motte  :  "Traite  Compl.,"  1725,  p.  412;    Mesnard,  1748;   Poederer,  1759. 

'10.  Traction  on  the  lower  jaw  with  two  fingers  and  on  the  upper  with  one 
finger,  and  traction  on  the  shoulder. — Giffars,  17:>4. 

'11.  Traction  on  the  upper  jaw  and  pressure  againsl  the  occiput  internally. 
Smellie,  1752;  Josephi,  1797;    Busch,   1801;  Froriep,  1818;  Ritgen,  Joerg.  1820; 
Wigand,  1820;  Lachapelle,  1821. 

'  12.  Traction  on  the  body  and  depression  of  the  neck  backward  with  the  thumb 
of  the  other  hand. — Japaner:  Shauron  von  (lenjct:    Kagama,  1751  or  17">l. 


1  'Trait.'  des  Maladies  des  Femmes  grosses,'  4th  edition,  1694,  p.  283. 

2  Op.  dt.f  vol.  i..  p.  311. 


BliEECH  PRESENTATIONS  73 

attitude  of  flexion.  Two  fingers  of  the  other  hand  are  applied  over  the 
child's  shoulders,  one  finger  on  each  side  of  the  neck.  Traction  is 
now  exerted  in  a  downward  and  backward  direction  until  the  head  is 
brought  through  the  pelvis.  The  passage  of  the  head  down  through 
the  pelvis  is  greatly  facilitated  by  an  assistant  or  nurse  pressing  the 
head  into  the  pelvis  from  above.  It  is  a  great  advantage  if  this  is 
done  during  a  uterine  contraction. 

Once  the  head  has  passed  the  brim  and  is  well  down  in  the 
cavity,  and  the  nape  of  the  neck  appears  below  the  symphysis — but 
on  no  account  before  then,  otherwise  dislocation  of  the  neck  will 
result — the  child  is  carried  well  up  on  to  the  abdomen  of  the  mother 
{Eig.  43).     At  this  stage  suprapubic  pressure  ceases,  otherwise  the 


'  13.  Traction  on  the  body  alone  over  the  shoulders  with  both  hands. — 
A.  Petit,  1753. 

'  14.  Pressure  from  without  on  the  head  and  traction  on  the  shoulders. — 
Pugh,  1753;  Kiwisch,  1846  ("Beitrage  zur  Geburtskunde,"  i.,  p.  69);  Goodell, 
1873. 

'  15.  Traction  by  the  operator  on  the  lower  jaw  and  shoulders,  and  by  an 
assistant  on  the  body  of  the  child,  and  pressure  by  a  second  assistant  from  with- 
out on  the  head.— Eschenbach  :  "  Grundlage  zum  Unterricht  einer  Hebamme" 
(11  Aufl.,  Eostock,  1687). 

'  16.  Hooking  the  chin  to  flex  it  on  the  neck,  expression  of  the  head  by  pressure 
upon  the  occiput  at  the  brow  externally. — Wigand,  1800  ("Beitrage  zur  Theor.  und 
prakt.  Geburtshulfe,"  Heft  11,  Hamburg,  1800,  p.  118)  ;  Lachapelle  (loc.  cit., 
pp.  336-338)  ;  K.  Euge  (Zeitschr.  f.  Geburtsch.  unci  Frauenkrankheiten,  von 
E.  Martin,  1876,  i.  p.  82) ;  Champetier  de  Eibes,  1879  ("  Du  Passage  de  la  tete 
Foetale  a  travers  le  detroit  Superieure  Eetreci  du  Bassin,"  p.  78,  Experience  IX.); 
A.  Martin,  1886  (Berl.  JcUn.  Wochenschrift,  1886,  p.  660) ;  Winckel :  "  Yerhand- 
lungen  des  11  Gynak.  Congress,"  Halle,  1888. 

'  17.  Pressure  on  the  head  from  within  and  traction  on  the  body.— Eitgen,  1820 
(Monatsschrift  f.  Geburtskunde,  viii.  233)  ;  Crede,  1854  ("  Klinische  Vortriige 
iiber  Geburtshulfe,  p.  763). 

'  18.  Traction  on  the  trunk  alone,  by  the  shoulders  and  feet  (the  Prague 
manipulation). — Kiwisch,  1846  (compare  No.  14);  Scanzoni,  1851. 

'  19.  Traction  on  the  upper  jaw,  pressure  against  the  occiput  internally,  and 
pressure  on  the  head  by  an  assistant  externally. — "Wigand,  1820  ;  Eitgen,  1848 ; 
Crede,  1854  ;  Ed.  Martin,  1865  (Monatsschrift  f.  Geburtskunde,  xxvi.  434). 

'20.  Depression  of  the  head  into  the  small  pelvis,  and  then  extraction,  com- 
bined with  expression. — Kristeller,  1867  (ibid.,  xxix.  383). 

'  21.  Traction  on  the  shoulders  by  the  operator  and  an  assistant ;  lighter 
traction  on  the  lower  jaw. — Ahltield,  1887  (,lBer.  u.  Arb.  aus  Marburg,"  1887, 
p.  151). 

'  Of  these  twenty-one  different  methods,  the  action  is — 

'  (1)  By  traction  only  and  upon  the  head  alone  in  Nos.  1  and  3;  upon  the  body 
alone  in  Nos.  13  and  18 ;  upon  head  and  body  in  Nos.  5,  6,  7,  and  10. 

'(2)  By  traction  and  pressure,  and  upon  the  head  alone  in  Nos.  2,  8.  9,  11,  16, 
19,  and  20;  upon  head  and  body  in  Nos.  4,  12,  14,  15,  and  21. 

'  (3)  By  pressure  only  in  Nos.  16  and  17." 


74 


OPERATIVE  MIDWIFERY 


head  will  be  forced  out  too  suddenly.  The  face  and  forehead  are  now 
carefully  guided  over  the  perineum,  after  which  the  occiput  escapes 
and  the  delivery  is  completed. 


Fig.  42. — The  First  stage  in  the  Delivery  of  the  After-coming  Head   Manriceau-Smellie- 

Veil  Method  .      Nagel.) 

The   illustrations   of    two   other   methods — the    Prague   and   the 
Wigand-Martin  (Figs.  44  and  45) — explain  sufficiently  the  manner  of 


BREECH  PRESENTATIONS 


!■> 


their  employment.  They  are  not  much  used,  the  former  because 
there  is  great  danger  of  injuring  the  spinal  column,  and  the  latter 
because  one  cannot  exert  so  much  traction.  They  are  useful,  however,, 
if  the  operator  is  single-handed. 

Another  difficulty  in  connexion  with  the  delivery  of   the  after- 
coming  head  is  its  extraction  in  cases  where  the  occiput  is  directed 


FlG.  43.— The  Completion  of  the  Delivery  of  the  After-coming  Head.    The  trunk  is  carried 
.up  towards  the  mother's  abdomen  (Mauriceau-Smellie-Yeit  Method).     (Nagel.) 


backwards.  Such  a  complication  is  very  rarely  encountered  when  the 
accoucheur  has  been  in  attendance  from  the  first,  for  in  all  dorso- 
posterior  cases,  if  a  spontaneous  rotation  of  the  back  to  the  front  does 
not  occur  with  the  escape  of  the  limbs,  a  very  slight  rotation  of  the 
ftetal  pelvis  is  sufficient  to  bring  it  about.  It  occasionally  happens, 
however,  that  the  child's  trunk  is  born  before  assistance  arrives,  or 


<<> 


OPERATIVE  MIDWIFERY 


that  the  rotation  manoeuvre  referred  to  is  not  carried  out,  when  of 
necessity  one  has  to  deal  with  a  dorso-posterior  position  of  the  head. 
In  such  a  position  rotation  may  sometimes  be  accomplished  by 
pressing  the  cheek  or  side  of  the  jaw;  but,  better  still,  by  passing  a 


Fig.  11.     The  Delivery  of  the  After-coming  Head  (Wigand-Martin  Method).      Nagel 

finger  into  the  mouth.  The  head  should  be  grasped  in  the  ordinary 
way  employed  for  delivering  the  after-coming  head.  The  head  is 
then  pushed  up  a  little  and  the  occiput  rotated  forwards.  If  sue])  a 
manoeuvre  is  carried  out,  the  head  and  trunk  must  be  rotated  to- 
gether ;  there  must  be  no  attempt  made  to  bring  about  the  rotation 


BREECH  PRESENTATIONS 


77 


of  the  bead  by  simply  turning  the  trunk,  for  that  may  readily  lead  to 
fracture  of  the  upper  part  of  the  spine.  As  stated  before,  I  do  not 
favour  such  a  device  as  trying  to  bring  about  rotation  by  pulling  or 
pushing  on  one  arm. 

In  some  cases  rotation  is  impossible,  either  because  the  head  is- 


FlG.  45. — The  Delivery  of  the  After-coming  Head  when  the  Occiput  is  Posterior  J 

(Prague  Method). 

too  firmly  fixed  in  the  pelvis,  or  because  the  chin  has  become  caught 
above  the  symphysis  pubis.  If  the  chin  is  down,  one  may  try  the 
ordinary  method  of  passing  a  finger  into  the  mouth  and  grasping  the 
shoulders  with  two  fingers  of  the  other   hand.      The  child  is  now 


7s  OPERATIVE  MIDWIFERY 

pulled  backwards,  and  then,  when  the  forehead  is  fixed  against  the 
posterior  surface  of  the  symphysis  pubis,  the  trunk  is  pulled  upwards 
on  to  the  abdomen  of  the  mother.  In  such  cases,  forceps  and  a  deep 
incision  laterally  into  the  perineum  will,  I  believe,  give  the  child  the 
best  chance.  In  cases  in  which  the  chin  slips  up,  and  which  will  some- 
times require  to  be  terminated  by  craniotomy,  one  should  attempt  to; 
deliver  the  head  by  the  Prague  rnanu'uvre  (Fig.  45).  Nagel  describes 
a  most  interesting  case  where  a  woman  delivered  herself  by  pulling 
the  child's  limbs  up  on  to  her  abdomen,  as  indicated  in  the  illustra- 
tion. If  the  child  is  of  any  size,  craniotomy  will  often  require  to 
be  performed,  and  one  has  little  hesitation  in  having  recourse  to  it, 
as  the  child  will  generally  be  dead. 

There  remains  only  one  other  matter  to  consider  in  connexion 
with  the  delivery  of  the  after -coming  head,  and  that  is  when  the 
latter  is  arrested  because  of  the  cervix  not  being  quite  sufficiently 
dilated.  Incidentally  I  referred  to  this,  and  pointed  out  the  danger 
of  its  occurrence  if  one  hastened  the  extraction  of  the  child  when 
the  os  was  not  sufficiently  dilated.  As  such  cases,  however,  occur, 
because  labour  has  often  to  be  accelerated,  I  will  describe  how  this 
difficulty  is  to  be  overcome.  In  most  cases,  I  believe,  the  best  treat- 
ment is  craniotomy,  for  in  the  vast  majority  of  such  cases  the  child  is 
dead  or  hopelessly  asphyxiated.  There  has  usually  been  great  delay 
with  the  arms,  and  very  probably  some  maternal  complication  which 
has  already  seriously  jeopardized  the  child.  If,  however,  the  child's 
•condition  is  still  such  that  its  life  is  worth  considering,  then  the  best 
procedure  is  to  make  two  deep  incisions  into  the  cervix.  It  is  abso- 
lutely profitless  to  try  to  dilate  the  cervix;  there  is  not  time  for  such 
a  proceeding. 

THE  BREECH  ARRESTED  AT  THE  PELVIC    FLOOR-  IMPACTION 
OF  THE  BREECH  IN  THE  PELVIC  CAVITV. 

This  is  by  no  means  an  uncommon  occurrence  in  primiparse.  In 
•most  cases  it  is  caused  by  uterine  inertia  ;  but  in  others  the  size  of 
•the  breech,  or  the  fact  that  there  is  some  little  pelvic  narrowing, 
accounts  for  the  condition.  But  there  is  another  cause  to  which  some 
writers  have  attached  a  good  deal  of  importance — viz.,  an  extended 
position  of  the  legs  along  the  body  of  the  child  (Fig.  46).  The 
most  important  and  interesting  paper  on  the  subject  in  the  English 
language  is  by  Griffith  and  Lea.1  In  this  position  the  legs  act  like 
splints  to  the  body,  and  prevent  the  lateral  flexion  of  the  trunk, 
>which  must  necessarily  occur  in   the  progress  of   the  birth  of   the 

]    Trans.  Lond.  Obst.  Soc,  189S,  vol.  xxxix.,  p.  13. 


BREECH  PRESENTATIONS 


79 


breech.  This  extension  of  the  legs  may  be  primary  or  secondary 
to  the  descent  of  the  breech,  and  one  sees  usually  which  it  has 
been  after  birth  by  the  attitude  the  child  assumes,  for  on  placing 


Fig.  46.— The  Breech,  with  Extended  Legs,  impacted  in  the  Pelvic  Cavity. 

"the  new-born  infant  on  the  bed  its  legs  immediately  take  up  the 
•extended  position  they  occupied  in  utero  if  the  condition  was  primary ; 
whereas,  if  it  was  secondary,  the  legs  seldom  become  so  completely 
■extended. 


.so  OPERATIVE  MIDWIFERY 

The  condition  should  he  suspected  when  the  hreech  is  found,  early 
in  labour,  low  down  in  the  pelvis,  and  when  the  foetal  heart  sounds 
are  heard  below  the  umbilicus.  As  can  be  readily  understood,  the 
presentation  by  abdominal  palpation  closely  resembles  one  of  the 
vertex.  No  doubt  abdominal  palpation  may  reveal  the  exact  position 
of  the  legs  if  the  conditions  are  favourable  for  palpation,  and  certainly 
the  head,  if  carefully  searched  for,  will  usually  be  felt  up  towards  the 
fundus. 

A  breech  arrested  in  the  pelvis  is  a  condition  which  may  cause 
the  obstetrician  much  trouble.  So  far  I  have  always  succeeded  in 
getting  it  delivered  by  one  of  the  following  devices  :  (a)  Bringing  down 
a  foot ;  {!>)  traction  with  the  fingers ;  (c)  traction  with  a  fillet  or  hook  ; 
(<1)  forceps. 

These  are  the  means  to  be  employed  if  the  child  is  alive.  If  the 
child  is  dead,  the  sharp  hook  or  the  cranioclast  must  be  used. 

One  usually  succeeds  with  a  finger  in  the  groin,  and,  as  a  rule,  one 
can  reach  the  anterior  groin  more  easily  than  the  posterior.  In  order 
to  get  the  forefinger  into  the  groin,  it  is  best  to  pass  it  up  over 
the  sacrum  and  to  make  traction  more  against  the  trunk,  for  there  is 
the  danger  that,  if  one  passes  it  over  the  thigh  and  exerts  traction  on 
the  thigh,  the  force  applied  may  fracture  it.  The  fact,  however,  that 
one  can  only  exert  a  moderate  force  usually  saves  one  from  doing 
this.  Sometimes  the  posterior  groin  can  be  more  easily  reached,  and 
occasionally  in  multipara?  I  have  even  managed  to  get  a  finger  into 
each  (Fig.  47).  Only  one  finger  should  be  employed  for  each  groin. 
If  two  are  used,  there  is  greater  danger  of  fracturing  the  thigh. 

The  successful  carrying  out  of  the  manipulations  described  is 
greatly  facilitated  by  pressure  from  above.  This  should  be  carried 
out  by  a  nurse  or  assistant,  but  only  when  the  uterus  is  contracting 
firmly.  The  best  plan  is,  just  before  the  'pain'  comes  on,  to  pass 
one  finger  into  the  groin,  and  so  be  ready  for  the  uterus  contracting; 
then,  when  the  contraction  is  at  its  height,  supplement  it  by  external 
pressure. 

I  have  always  found  great  difficulty  in  applying  a  fillet  (Fig.  48), 
either  by  means  of  a  carrier  or  catheter.  Both  the  catheter  and 
carrier  are  used  in  the  same  way.  The  instrument  is  passed  up  over 
the  sacrum,  and  the  hooked  part  is  then  rotated  over  the  thigh  :  two 
fingers  are  then  passed  up  between  the  buttocks,  and  the  rubber 
tubing  or  silk  ligature  seized  and  a  piece  of  gauze  attached:  this 
latter  is  then  pulled  over  the  groin.  Nagel1  recommends  the  carrying 
of  the  gauze  over  by  means  of  a  plain  gold  wedding-ring  thoroughly 
sterilized,  and  passed  up  from  behind  into  the  groin.  Jellett- 
1  Op.  rit.,  p.  ;57.  -  '  Manual  of  Midwifery,'  2nd  Edition,  1910,  p.  1067. 


BlIEECH  PRESENTATIONS 


81 


recommends  employing  a  roll  of  gauze  as  follows :  '  Take  a  small 
piece  of  double  gauze  about  18  inches  long  and  2  inches  wide, 
and  rolled  like  a  bandage.  The  free  end  of  this  roll  is  held  in 
the  left  hand,  and  the  roll  itself  is  pushed  upwards  between  the 
thigh  and  the  anterior  pelvic  wall  in  such  a  manner  that  as  it 
advances  it  unrolls.  As  soon  as  it  has  been  pushed  above  the  angle 
of  the  groin  it  is  pushed  inwards  across  the  latter  until  it  comes  to 


Fig.  47. — Impaction  of  the  Breech — Delivery  with  a  Finger  inserted  into  Each  Groin. 

(Nagel.) 


lie  between  the  thighs.  Then  the  fingers  are  pushed  upwards  from 
below  between  the  thighs,  and  the  roll  of  gauze  caught  and  drawn 
downwards.' 

But  a  fillet  is  not  altogether  safe,  for  there  is  danger  not  only  of 
bruising  the  soft  parts,  but  of  fracture  and  dislocation  resulting,  if  the 
gauze  is  not  passed  exactly  into  the  fold  of  the  groin.  The  blunt  hook 
is  even  worse,  and  although  I  have  employed  it  once  or  twice  without 
doing  any  injury,  I  have  on  one  occasion  fractured  a  limb.     It  must, 

6 


82 


OPE  I I  AT  |  \  E3  MIDWIFERY 


however,  be  risked  if  it  is  impossible  to  deliver  the  breech  by  means 
of  the  fingers,  forceps,  or  a  fillet ;  it  should  be  passed  along  the  dorsal 


Fig.  18. —  Impaction  of  the  Breech— Delivery  by  Means  of  the  Fillet. 

aspect  of  the  breech  and  then  rotated  into  position,  the  point  being 
guided  over  the  thigh. 


BREECH  PRESENTATIONS 


83 


Some  obstetricians  have  expressed  themselves  in  favour  of  forceps 
in  impacted  breech,  although  most  writers  are  opposed  tophe  treat- 


Fig.  49. — Impaction  of  the  Breech — Delivery  by  Means  of  Forceps. 

ment  (Fig.  49).     Various  attempts  have  been  made  to  devise  forceps 
suitable  for  the  breech,  but  they  have  always  proved  unsatisfactory. 


si  OPERATIVE  MIDWIFERY 

I'pon  several  occasions  I  have  delivered  the  breech  with  forceps 
successfully  when  I  have  failed  to  do  so  with  my  fingers.  I  must 
also  admit  that  I  have  frequently  failed  when  the  breech  was 
firmly  impacted.  The  great  difficulty  is  getting  a  good  grasp,  for 
the  two  thighs  are  at  different  levels.  I  always  try  to  grasp  the 
breech  transversely  with  a  blade  over  each  limb  (Fig.  49).  Naturally, 
one  must  be  cautious  in  the  amount  of  pressure  and  traction  exerted, 
for  if  one  compresses  the  blades  too  firmly  injury  may  be  done  to 
the  fu'tal  pelvis,  and  if  one  pulls  too  strongly  and  the  blades  slip, 
the  maternal  parts  may  be  seriously  lacerated.  Here,  again,  great 
help  will  be  obtained  by  an  assistant  pressing  the  uterus  daring 
a  contraction. 

^Vith  increased  experience  of  impacted  breech  presentations,  1  am 
more  and  more  convinced  that  the  best  treatment,  when  one  cannot 
pull  down  the  breech  with  one's  fingers,  is  to  push  the  breech  out  of 
the  maternal  pelvis  and  bring  down  a  leg.  In  almost  all  cases,  even 
those  which  look  hopeless,  with  deep  anaesthesia  and  the  patient  in  the 
left  lateral  position,  the  advantages  of  which  position  have  been  con- 
sidered, it  will  be  found  possible  to  dislodge  the  breech  and  bring  down 
a  leg.  Barnes  states  that  he  has  never  failed  in  doing  so  ;  while, 
going  farther  back,  Smellie,  La  Motte,  and  others,  describe  cases 
where,  even  when  the  f octal  pelvis  was  showing  at  the  vulva,  the 
former  was  pushed  back  and  a  leg  brought  down.  It  has  been 
suggested  in  cases  where  the  legs  are  extended  not  to  try  and  bring 
down  the  limbs',  but  simply  to  bend  them  at  the  knee  so  as  to 
allow  the  limb  to  take  the  natural  flexion.  I  very  much  doubt  if 
such  a  mameuvre  will  be  successful  with  the  impacted  breech.  A- 
I  have  already  mentioned,  it  is  often  emploj'ed  when  the  breech 
is  movable. 

Should,  however,  it  be  impossible  to  deliver  the  child  by  these 
various  devices  mentioned,  and  the  bringing  down  of  a  leg  be  also  im- 
possible, there  only  remains  extraction  by  means  of  the  cranioclast.  If 
this  instrument  is  employed,  the  middle  blade  is  introduced  into  the 
rectum  of  the  child,  and  the  two  other  blades  applied  outside  its 
pelvis.  Naturally,  if  one  had  ever  to  have  recourse  to  such  an  instru- 
ment, the  after-coming  head  should  also  be  perforated,  as  otherwise 
the  child  might  be  born  alive. 

There  is  one  other  course  open — viz.,  symphysiotomy  or  pubiotomy. 
It  is  questionable  if  such  a  procedure  is  justifiable,  for  the  foetal  mor- 
tality, under  the  circumstances,  must  be  very  high  indeed.  It  might 
be  argued  that,  at  the  stage  we  are  considering  (a  breech  impacted  in 
the  pelvis),  the  child's  life  has  not  been  much  jeopardized ;  conse- 
quently, although  I  would  not  care  to  have  recourse  to  the  operation. 


BREECH  PRESENTATIONS  85 

I  can  understand  another  taking  up  a  different  attitude,  if  the  foetal 
heart  sounds  were  satisfactory. 

Prophylactic  Cephalic  Version  in  Breech  Presentations.— 
There  is  a  matter  in  connexion  with  breech  presentations  which  is 
worthy  of  consideration,  but  which  I  have  not  mentioned  until  now, 
as,  properly  speaking,  it  does  not  come  into  consideration  in  con- 
nexion with  labour.  I  refer  to  prophylactic  external  cephalic  version, 
which  in  this  country  has  found  so  strong  an  advocate  in  Spencer.1 
Quite  a  number  of  accoucheurs,  also,  in  other  countries  express 
themselves  favourably  regarding  it.  Personally,  I  entirely  approve  of 
the  treatment,  and  have  carried  it  out  successfully  upon  one  or  two 
occasions.  It  is  best  performed  a  week  or  two  before  term,  at  the 
time  of  the  examination,  which  all  recommend  should  be  made 
about  the  thirty  -  sixth  week.  Not  infrequently  in  multipara  it 
may  be  successfully  performed  early  in  labour.  I  have  heard  a 
University  teacher  of  midwifery  criticize  the  treatment,  and  refer  to 
it  as  a  return  to  the  practice  of  Hippocrates.  But  such  criticism  is 
not  to  the  point,  for  Hippocrates  employed  internal  cephalic  version, 
and  the  os  had  to  be  sufficiently  dilated  to  admit  of  the  introduction 
of  the  operator's  hand.  In  the  case  of  prophylactic  version,  recom- 
mended by  Spencer  and  others,  the  manipulations  are  entirely 
external.  Of  equally  little  account  is  the  other  argument  urged 
'against  the  treatment,  that  in  the  case  of  failure  a  more  unfavour- 
able— say  an  oblique — presentation  is  established.  I  have  never 
found  such  a  result  in  the  cases  in  which  I  have  failed.  The  objec- 
tion is  purely  theoretical,  for  an  oblique  presentation  in  which  the 
head  remains  higher  invariably  becomes  a  breech  presentation  when 
labour  starts.  At  the  worst,  therefore,  one  can  do  no  harm.  I  was 
inclined  to  think  so  until  quite  recently,  when  I  had  rather  an  unfor- 
tunate experience.  When  carrying  out,  with  a  good  deal  of  difficulty, 
cephalic  version  about  the  thirty-sixth  week  of  pregnancy  in  order 
that  I  might  alter  a  breech  into  a  head  presentation  and  test  the 
relative  size  of  the  head  and  the  pelvis  (the  pelvis  was  deformed), 
very  sharp  haemorrhage  occurred,  and  I  was  compelled  to  plug  the 
vagina.  The  child  was  shortly  afterwards  born  dead.  I  had  in  this 
case  actually  caused  a  separation  of  the  placenta,  which  was  situated 
on  the  anterior  uterine  wall. 

Should  the  correction  of  the  presentation  succeed,  the  child  is 
maintained  in  its  new  position  by  fixing  the  head  in  the  pelvis  and 
applying  a  binder  or  other  abdominal  support. 

i  Brit.  Med.  Jourti.,  1901,  vol.  i.,  p.  1192. 


CHAPTER  VI 

DYSTOCIA  THE   RESULT  OF   ABNORMALITIES   AFFECTING  THE 

FCETUS— Continued 

Transverse  or  Oblique  Presentations. 

Of  all  presentations,  oblique  are  the  most  unfavourable,  for,  except 
under  the  very  rare  conditions  which  will  be  referred  to,  spontaneous 
delivery  is  impossible.  The  presentation  is  often  spoken  of  as  trans- 
verse, but,  as  a  matter  of  fact,  the  child  lies  obliquely  in  the  uterus. 
A  popular  term  for  the  presentation  is  '  cross-birth.'  The  frequency  of 
the  condition  is,  roughly,  1  in  125  births. 

Theoretically,  any  part  of  the  trunk  from  head  to  breech  may 
present,  and  the  older  writers  were  in  the  habit  of  distinguishing 
various  presentations  of  back  and  abdomen  ;  but  from  the  fact  that 
an  oblique  presentation  ultimately  resolves  itself  into  a  shoulder,  it 
is  quite  unnecessary  to  consider  the  refinements  of  the  presentation. 

As  the  position  of  the  child  may  be  either  dorso-anterior  or 
dorso  -  posterior,  with  the  head  to  either  side,  there  are  four 
transverse  positions.  The  dorso-anterior  are  rather  more  frequent 
than  the  posterior,  for  in  about  three-fifths  of  the  cases  the  back  is  to 
the  front.  The  head  is  also  rather  oftener  directed  towards  the  left 
side,  so  that  the  first  position  is  the  most  common  (Fig.  50).  Accord- 
ing to  Raineri,1  the  right  shoulder  presented  in  68  per  cent.,  and  the 
back  of  the  child  in  60  per  cent,  of  cases. 

It  is  not  possible  to  discuss  here  in  detail  the  etiology  of  this 
presentation.  I  can  only  mention  some  of  the  factors  which  favour 
its  occurrence.  On  the  part  of  the  mother  multiparity  (86  per  cent.), 
a  large  and  flabby  uterus  and  a  pendulous  abdomen — consequently 
more  common  amongst  the  poorer  classes — an  overdistended  cavity 
from  excessive  liquor  amnii  or  plural  pregnancy,  the  presence  of 
placenta  prarvia  (7  per  cent.),  and  a  marked  disproportion  between  the 
head  and  the  pelvis,  and  especially  a  narrow  pelvis  (14  per  cent.),  are 
the  most  important. 

1  Ep.  Brit.  Med.  Journ.,  1905,  vol.  xi.,  No.  9. 
86 


TRANSVERSE  OR  OBLIQUE  PRESENTATIONS  87 

An  interesting  group  of  cases,  referred  to  by  all  writers,  and  one 
that  may  give  rise  to  special  trouble,  is  where  malformation  of  the  uterus 
exists,  especially  such  slighter  forms  as  uterus  cordiformis,  arcuatsu, 
or  duplex  subseptus.  In  such  conditions  one  part  of  the  child  occupies 
one  half,  and  the  rest  the  other  half  of  the  uterus.  Vogel,1  writing 
especially  upon  transverse  presentations  in  primipara;,  states,  that  in 
eighty-six  cases  of  transverse  presentation  a  uterus  arcuatus  existed 
in  nine,  and  in  the  eight  cases  in  which  the  presentations  occurred 
in  primiparre,  it  was  observed  in  as  many  as  five.     I  am  inclined  to 


Fig.  50. — First  Oblique  Position. 

think,  however,  that  in  some  of  these  cases  the  shape  of  the  uterus 
was  the  result,  not  the  cause. 

Very  rarely  ovarian  and  uterine  tumours  may  influence  the  occur- 
rence of  this  presentation. 

On  the  part  of  the  child  may  be  mentioned  prematurity,  macera- 
tion, and  deformity. 

The  natural  course  of  labour  in  an  oblique  presentation  is  for  the 
shoulder  to  become  pushed  down  into  the  pelvis,  and  if  the  malpres- 
entation  is  not  corrected,  for  the  labour  to  continue  until  the  uterus 
becomes  exhausted  or  ruptures.  Very  occasionally,  however,  spon- 
taneous delivery  does  occur,  although  one  must  never  reckon  upon 
such  a  termination.  If  it  does,  it  takes  place  in  one  of  the  three 
following  ways:  («)  Spontaneous  version,  (6)  spontaneous  evolution, 

i  Z<it.  f.  Geb.  u.  Gyn.,  1900.  Bd.  xliii.,  Heft  2,  p.  312. 


88 


OPERATIVE  MIDWIFE  I;  V 


(c)  birth  with  doubled-up  body  (partus  conduplicato  corpore).  By 
spontaneous  version  is  meant  the  changing  of  an  oblique  presenta- 
tion into  one  of  the  head  or  breech  by  the  uterine  contractions. 
Naturally,  it  is  difficult  to  estimate  the  frequency  of  this  occurrence, 
but  according  to  C.  Braun  conversion  into  a  breech  occurred  in 
75  per  cent,  of  cases  after  rupture  of  the  membranes,  and  in  80  per 


Fig.  51. — Spontaneous  Evolution.    (Bumni. 

cent,  into  a  head  before  their  rupture.  Some  writers  have  dis- 
tinguished between  spontaneous  rectification  and  spontaneous  version, 
the  former  being  an  alteration  into  a  head  presentation  and  the  latter 
an  alteration  into  a  breech. 

Spontaneous   evolution   (Fig.   51),   which   was  first  described  by 
Douglas   and   later   by   Dubois,    is   a  very   much    rarer   occurrence. 


TRANSVERSE  OR  OBLIQUE  PRESENTATIONS 


89 


Winckel  puts  it  at  8£  per  cent.,  but  Von  Franque  found  it  to  occur 
only  twelve  times  in  2,000  transverse  presentations.  Reed1  goes  into 
the  subject  very  fully.  I  have  only  seen  it  once,  and  in  that  case  the 
child  was  premature.  Indeed,  it  can  only  occur  in  a  living  child  when 
the   latter  is  small  or  premature,  and  when  the  maternal  pelvis  is 


Yig.  52. — Partus  Conduplicato  Corpore.     (Author's  Case.) 

unusually  large.  In  this  variety  of  spontaneous  birth  the  shoulder 
of  the  child  is  driven  down  into  the  pelvis  and  becomes  fixed  under- 
neath the  symphysis,  while  the  trunk,  breech,  and  limbs  are  driven 
past.  Finally,  the  other  shoulder  and  head  escape.  Almost  invariably 
the  arm  is  prolapsed  beforehand. 

1  Amer.  Jo  urn.  Obstct.,  September,  1905. 


SO  OPERATIVE  MIDWIFE  I  ;V 

In  the  third  variety,  the  birth  with  the  body  doubled  up  (partus 
conduplicato  corpore),  the  presenting  part  is  driven  down.  If  an  arm 
has  prolapsed,  it  will  be  the  region  below  the  shoulder,  but  if  an  arm 
has  not  fallen  down,  it  may  be  any  part  of  the  trunk.  The  head 
and  the  thorax  or  pelvis  are  pressed  together,  and  escape  together 
from  the  parturient  canal.  The  illustration  (Fig.  52)  represents  a 
case  recently  under  my  care  in  the  Maternity  Hospital.  Winckel 
found  it  occurred  four  times  in  130  cases.  Von  Franque  puts  it  at 
2*5  per  cent.  When  it  occurs  the  child  is  usually  small,  premature, 
and  macerated. 

Diagnosis. — A  suspicion  of  a  transverse  presentation  is  often 
aroused  by  simply  inspecting  the  abdomen,  for  the  uterus  is  enlarged 
transversely  and  shortened  vertically. 

By  abdominal  palpation  a  swelling  is  recognized  on  both  sides  of 
the  uterus,  the  one  being  the  hard  round  head,  and  the  other  being  the 
breech.  The  head  is  invariably  lowermost;  indeed,  if  that  is  not  so, 
the  presentation  will  almost  invariably  become  a  breech.  When  the 
membranes  are  still  intact,  there  is  little  difficulty  in  palpating  the 
head  and  breech,  and  the  curved  back  connecting  the  two  prominent 
parts  if  the  breech  is  to  the  front ;  but  when  the  liquor  amnii  is  small 
in  quantity  or  has  drained  away,  differentiation  of  the  two  poles  may 
be  difficult,  for  the  child  gets  crushed  up  in  the  uterus.  If  there 
is  difficulty  in  differentiating  the  two  poles,  a  confirmation  of  the 
suspicion  of  the  presentation  will  be  obtained  by  finding  no  presenting 
part  engaging  in  the  pelvic  brim,  unless  the  arm  is  prolapsed  or  the 
shoulder  is  well  engaged. 

By  vaginal  examination  there  will  be  no  difficulty  in  reaching  the 
presenting  part  if  labour  has  been  in  progress  for  some  time.  The 
shoulder,  the  part  which  ultimately  comes  to  present,  is  a  small  round 
body.  It  can  only  be  distinguished  from  the  other  parts  of  the  child 
which  resemble  it,  by  feeling  the  clavicle  or  ribs  ;  the  latter  is  the 
most  important  landmark,  and  should  always  be  searched  for.  In  all 
cases  of  doubt  the  parturient  should  be  deeply  anaesthetized,  and  a 
thorough  examination  of  the  presentation  made. 

In  a  considerable  number  of  cases  of  transverse  presentation  one 
or  more  limbs  prolapse.  The  prolapse  of  a  foot,  or  of  a  foot  and  arm, 
as  illustrated  (Fig.  53),  is  rare,  but  it  is  by  no  means  uncommon  to 
find  an  arm  slipping  down.  When  an  arm  prolapses,  most  commonly 
the  hand  is  the  presenting  part,  but  it  may  occasionally  be  the  elbow. 
The  hand  is  to  be  distinguished  from  the  foot  by  the  absence  of  the 
projecting  os  calcis,  and  on  that  alone  one's  diagnosis  should  be  made. 
It  is  perfectly  true  that  the  fingers  are  larger  than  the  toes,  and  that 
the  thumb  moves  more  freely  than  the  large  toe  ;  but  if  one  trusts  to 


TRANSVERSE  OR  OBLIQUE  PRESENTATIONS     91 

such  distinguishing  features  mistakes  will  constantly  be  made.  Let 
me  again  repeat  that  the  projecting  heel  is  the  only  landmark  that 
can  be  relied  upon. 

The  particular  arm  which  has   prolapsed  can  be  recognized  by 


Fig.  53. — Prolapse  of  Hand  and  Foot  in  an  Oblique  Presentation. 

i  Photographed  from  Van  Rymsdyke's  drawing  in  the  Hunterian  Museum,  Glasgow 

University.) 

shaking  hands  with  the  foetus  (Fig.  54).  If  one  does  this  with  the 
right  hand,  then  it  is  the  right  arm  which  has  prolapsed  ;  if  with  the 
left,  then  it  is  the  left  arm  of  the  child  which  is  down.  Naturally,  if 
the  arm  of  the  child  should  happen  to  be  completely  twisted  a  mistake 
might  arise,  but  that  practically  never  occurs. 


92 


OPERATIVE  MIDWIFERY 


l>ut  still  more  may  be  diagnosed  from  the  prolapsed  arm,  for  if 
the  hand  is  presenting,  the  thumb  points  to  the  head. 

In  addition  to  the  arm,  one  often  finds  that  the  cord  prolapses  in 
transverse  presentations.  Nor  is  this  to  be  wondered  at,  as  the 
umbilicus  is  brought  so  near  the  pelvic  brim. 

In  those  rare  cases  of  transverse  presentation  where  the  back  or 
the  front  of  the  total  thorax  or  abdomen  are  the  presenting  part-, 
there   may    be   some   difficulty   in    diagnosing   the    exact   condition. 


Fig.  54.- 


-DiatiDguishing  the  Particular  Hand  which  lias  prolapsed  by 
Shaking  Hands  with  the  Foetus. 


When  it  is  the  front  of  the  trunk,  this  difficulty  is  not  so  great,  for  the 
ribs  or  umbilicus  will  be  easily  felt.  When,  however,  it  is  the  back, 
as  in  the  case  of  partus  conduplicato  corpore,  mistakes  may  readily 
occur  if  the  arm  has  not  prolapsed.  In  a  case  (Fig.  52)  quite 
recently  in  the  Maternity  Hospital,  the  presentation  was  mistaken 
by  the  house-surgeon  and  nurse  for  a  breech.  Theoretically,  by 
feeling  the  spinous  processes  of  the  vertebrae,  the  exact  nature  of  the 
presentation  should  be  recognized ;    but  in  the  case  I  refer  to  the 


TRANSVERSE  OR  OBLIQUE  PRESENTATIONS  93 

^edematous  swelling,  which  formed  over  the  back,  masked  this  land- 
mark entirely. 

Again  let  me  say,  always  put  the  patient  under  an  anaesthetic  and 
make  a  thorough  examination,  rather  than  remain  in  the  slightest 
doubt  regarding  the  presentation. 

Prognosis. — The  prognosis  for  both  mother  and  child  in  oblique 
presentations  is  decidedly  less  favourable  than  in  any  other.  As 
operative  interference  is  always  necessary,  the  dangers  of  sepsis  and 
of  injury  to  the  parturient  canal  are  very  decidedly  increased. 

As  will  be  seen  when  considering  rupture  of  the  uterus,  this 
accident  is  by  no  means  uncommon.  In  my  cases  of  rupture  the 
presentation  was  transverse  in  17  per  cent.,  while  in  Ivanoff's1  it 
was  so  in  32  per  cent.  It  is  needless  to  say  that  in  oblique  presenta- 
tions there  is  not  the  same  proportion  of  raptures.  The  frequency 
of  rupture  of  the  uterus  in  transverse  presentation  is  variously 
stated.  As  far  as  I  can  judge,  however,  it  occurs  about  1  in  100 
to  150  cases.  The  rupture,  although  usually  described  as  uterine,  is 
very  generally  in  the  vaginal  vault.  The  most  important  practical 
point  in  this  connexion,  however,  is  that  the  rupture  is  invariably 
violent — viz.,  is  produced  while  attempts  at  rectification  are  being 
made.  Spontaneous  rupture  is  very  uncommon,  and  occurs  in  only 
about  1  in  300  cases.  The  operator,  therefore,  must  carry  out  his 
manipulations  of  version  with  great  care,  especially  in  cases  where 
the  membranes  have  ruptured  some  time  previously,  and  the  uterine 
wall  is  firmly  grasping  the  child. 

The  foetal  mortality  in  oblique  presentations  is  enormous,  some- 
where about  40  per  cent.  Winckel  for  883  transverse  presentations 
found  8-3  per  cent,  born  macerated,  and  33  per  cent,  died  during 
labour.  Many  factors  contribute  to  this  high  death-rate,  among 
which  may  be  mentioned  prematurity  of  the  child,  prolapse  of  the 
cord,  and  malformation  of  the  maternal  pelvis,  rendering  extraction  of 
the  child  difficult.  The  prognosis  is  also  unfavourably  affected  by 
prolapse  of  an  arm. 

Treatment. — Were  the  question  asked,  What  is  the  treatment  of 
oblique  presentation  ?  the  immediate  reply  would  be,  rectification  of 
the  presentation  by  version.  Such  an  answer  is,  however,  not  entirely 
correct.  There  are  certain  cases,  where  the  shoulder  has  become  im- 
pacted and  the  uterus  is  tetanically  contracted,  when  version  is  abso- 
lutely contra-indicated,  and  it  is  because  many  fail  to  recognize  this, 
and  fail  to  appreciate  the  limitations  of  version,  that  I  have  introduced 
the  consideration  of  treatment  of  oblique  presentations  in  this  some- 
what crude  manner.     Fortunately,  the  number  of  cases  encountered  in 

1  Annal.  de  Gyn.,  1903. 


:•!  OPERATIVE  MIDWII  i;i:v 

practice  where  the  shoulder  is  impacted  and  version  is  contra-indicated 
are  not  numerous,  for  they  result,  ;is  a  rule,  from  inattention  and 
carelessness  on  the  part  of  those  in  attendance. 

Having  sounded  this  warning  note  regarding  the  dangers  of 
version  in  certain  cases,  let  us  consider  the  treatment  of  oblique 
presentations  under  the  following  headings  : 

1.  When  the  presentation  is  recognized  during  pregnancy. 

2.  When  it  is  recognized  during  labour. 

3.  When  the  shoulder  is  impacted. 

1.  When  the  Presentation  is  recognized  during-  Pregnancy. — 
On  several  occasions  I  have  emphasized  the  importance  of  examining 
a  pregnant  woman  a  week  or  two  before  labour.  Here,  again,  will 
be  seen  the  great  advantage  of  doing  this,  for  an  opportunity  of 
recognizing  and  correcting  an  oblique  presentation  will  then  occur. 

Since  Pinard  and  Leopold  perfected  abdominal  palpation,  and  this 
most  valuable  method  of  examination  has  become  universal,  the 
correction  of  oblique  presentations  during  pregnancy  has  become  the 
recognized  treatment.  Long  ago,  however,  it  was  hinted  at,  and 
the  postural  treatment  for  the  condition  is  of  ancient  date.  The 
postural  treatment  consists  in  placing  the  patient  on  the  side  towards 
which  the  head  is  directed,  so  that  when  the  breech  falls  over  the 
head  is  pushed  down  towards  the  brim.  This  postural  treatment  is 
often  successful  up  to  about  the  thirty-fourth  week,  but  later  than 
that  the  presentation  is  so  fixed  that  the  foetus  can  seldom  be  dislodged 
by  simple  alterations  in  the  position  of  the  mother. 

Perfected  external  version  is,  as  has  been  stated,  of  comparatively 
recent  date.  It  is  now  very  widely  practised  in  all  maternity 
hospitals,  especially  on  the  Continent,  where  pregnant  women  so 
often  seek  advice  at  the  outdoor  department  of  the  hospitals.  The 
argument  still  advanced  against  the  treatment  is  that  the  child 
frequently  slips  back  into  its  old  position,  even  when  the  manipula- 
tions are  successful.  But  even  admitting  that  it  was  successful  in  only 
2  or  3  per  cent,  of  cases,  that  would  be  quite  a  sufficient  argument 
in  its  favour.  Besides,  in  cases  which  return  to  their  old  position 
matters  are  left  no  worse,  and  there  is  this  great  advantage,  that  the 
nature  of  the  condition  is  known  beforehand,  and  so  the  patient  can  be 
warned  of  the  danger  of  the  presentation  and  the  necessity  of  seeking 
advice  whenever  labour  commences.  Unfortunately,  in  this  country 
one  has  not  many  opportunities  of  correcting  the  position  during 
pregnancy,  for  so  few  seek  advice  prior  to  the  onset  of  labour.  I  can 
give  no  exact  figures  of  the  successes  from  the  treatment,  although 
I  have  noted  a  considerable  number. 

The  manner  in  which  external  version  is  carried  out  is  detailed 


TRANSVERSE  OR  OBLIQUE  PRESENTATIONS     95 

lsewhere  (Chapter  XXII.).  Having  brought  the  child  into  a  correct 
losition,  the  head  should  be  seized  between  the  two  hands  and  pushed 
nto  the  pelvis ;  pads  should  then  be  placed  along  the  sides  of  the 
iterus,  and  a  firm  binder  round  the  abdomen  or  Pinard's  ceinture 
jfeocique  should  be  applied.  The  patient  is  seen  at  intervals,  and 
hould  the  foetus  have  slipped  into  its  former  malposition  this  is 
.gain  corrected.  Occasionally  it  has  to  be  done  many  times,  but 
isually  there  is  less  difficulty  in  carrying  out  the  manipulations  on 
ach  succeeding  occasion. 

2.  When  the  Malpresentation  is  recognized  during-  Labour. — 
3y  taking  up  the  attitude  of  trying  always  to  determine  the  presenta- 
ion  during  pregnancy,  one  increases  enormously  the  chance  of  seeing 
iblique  presentations  early  in  labour.  The  importance  of  this  to> 
uother  and  child,  and  especially  to  the  child,  cannot  be  overestimated. 

External  version  is  still  often  possible  early  in  labour,  if  the  mem- 
>ranes  are  unruptured,  and  it  is  especially  easy  in  those  cases  im 
vhich,  prior  to  labour,  corrections  have  been  made. 

Should  the  external  method  fail,  the  question  arises  whether 
mmediate  attempts  by  other  methods  should  be  employed,  or  the 
abour  be  allowed  to  proceed  until  the  os  is  considerably  dilated. 
\Iany,  especially  in  this  country,  favour  the  immediate  correction  by 
nsans  of  the  bipolar  method  of  Braxton  Hicks,  and  I,  too,  incline  to 
his  procedure.  In  many  cases  it  can  be  carried  out  without  rupturing 
he  membranes.  But  even  if  the  membranes  do  rupture  the  child  is 
lot  in  danger,  unless  the  cord  prolapse.  Impaction  of  the  shoulder 
loes  not  occur  until  labour  has  been  long  in  progress  and  the  os  well 
lilated.  The  mistake  made  by  those  who  favour  early  bipolar  version 
s  to  proceed  to  internal  version  if  they  find  the  membranes  ruptured. 
t  always  increases  the  risks  to  the  child  to  dilate  forcibly  the  cervix 
.nd  perform  internal  version. 

When  rupture  of  the  membranes  occurs  and  bipolar  version  has 
lot  succeeded,  internal  version  should  be  delayed  until  the  os  is  well 
lilated. 

With  both  varieties  of  version  either  the  head  or  the  breech  may 
>e  brought  down,  but  while  external  and  bipolar  cephalic  version  are 
■ften  successful,  internal  cephalic  version  seldom  is.  Details  regarding 
he  operation  of  version  are  given  in  Chapter  XXII. 

Having  turned  the  child  and  brought  down  a  foot,  the  progress  of 
he  case  should  be  left  to  Nature,  and  the  delivery  hastened  only  if  the 
•s  is  fully  dilated,  or  the  mother's  or  child's  life  is  in  danger  from  some 
■dditional  complication.  A  very  large  number  of  children  are  lost  by 
tastening  the  delivery.  No  doubt,  with  the  foot  hanging  out  of  the 
anal,  one  is  very  much  tempted  to  drag  upon  it,  but  the  result  is 


96  OPERATIVE  MIDWIFERY 

always  the  same — the  arms  and  after-coming  head  are  caught  hy  the 
undilated  os  uteri. 

;.  When  the  Shoulder  is  Impacted. — The  obstetrician  of  little 
experience  will  find  it  a  difficult  matter  to  decide  when  he  should 
desist  from  making  attempts  at  version  in  cases  where  the  wal 
have  drained  away  and  the  shoulder  is  impacted  in  the  pelvis.  To 
desist  only  after  many  fruitless  attempts  have  been  made  is  not 
a  right  attitude  to  assume,  for  during  these  attempts  much  injury  may 
be  done.  Naturally,  the  greater  the  operator's  experience,  the  more 
often  will  he  be  successful,  but  no  matter  how  experienced  he  is,  there 
are  cases  in  which  he  cannot  perform  version  with  safety,  and  mast 
have  recourse  to  decapitation.  I  have  frequently  found  that  medical 
practitioners  consider  it  a  disgrace  if  they  fail  to  perform  version. 
They  forget  that  all  operations  have  their  limitations. 

In  a  case  of  impacted  oblique  presentation,  one  should  first  of  all 
satisfy  oneself  regarding  the  condition  of  the  child.  In  most  cases 
the  condition  is  unsatisfactory :  the  child  is  dead,  or  its  vitality  so  low- 
that  its  life  need  not  be  considered  ;  consequently,  one  should 
•consider  only  the  mother.  The  foetus  should  therefore  be  decapitated 
and  delivered.  But  the  reader  may  say,  How  is  one  to  be  sure  of  the 
death  or  impending  death  of  the  fcetus  ?  Auscultation  of  its  heart 
sounds  through  the  abdominal  wall  is  difficult  owing  to  the  restless- 
ness of  the  parturient  and  the  firm  retraction  of  the  uterus.  Should 
that  be  so,  the  hand  passed  a  little  way  into  the  uterus  will  usually 
encounter  the  umbilical  cord  and  permit  of  an  estimate  being  formed 
of  the  strength  and  frequency  of  the  fcetal  heart.  It  must  not  be 
forgotten  that  in  passing  a  hand  into  the  uterus  for  this  purpose,  and 
more  especially  for  the  purpose  of  performing  version,  the  parturient 
must  be  deeply  anesthetized.  Internal  manipulations  are  infinitely 
more  dangerous  and  difficult  when  one  attempts  to  perform  them 
with  the  woman  only  partially  anesthetized.  Should  by  any  chance 
the  child's  vitality  be  satisfactory,  a  little  more  may  be  risked,  but, 
personally,  I  desist  from  making  attempts  at  version,  no  matter  what 
the  condition  of  the  child  is,  when  I  find  a  very  much  thinned  out 
lower  uterine  segment  with  a  well-marked  retraction  ring  above  the 
head.  To  pass  the  hand  into  the  uterus  and  push  back  the  retraction 
ring  with  the  back  of  the  hand  and  allow  the  fcetal  head  to  slip 
up  along  the  palm  of  the  hand  may  sometimes  be  successful,  but  it  is 
difficult  and  dangerous,  unless  the  accoucheur  has  had  considerable 
experience  (Chapter  XXIX.). 


CHAPTER  VII 

DYSTOCIA   THE   RESULT   OF  ABNORMALITIES  AFFECTING  THE 

FCETUS— Continued 

Malformation  of  the  Foetus. 

Abnormal  Size  of  the  Foetus  as  a  Whole. — Undue  size  of  the  foetus 
may  be  general  or  confined  to  certain  parts — the  head,  the  shoulders, 
the  thorax,  the  abdomen,  the  pelvis. 

It  is  peculiar  to  certain  women  to  have  large  children.  I  recently 
attended  a  patient  where  the  first  child  weighed  12  pounds  and  the 
second  weighed  11  pounds.  Speaking  generally,  where  the  parents 
are  of  large  stature  the  children  are  above  the  normal.  This  is  most 
markedly  seen  in  the  case  of  giants.  Next  to  heredity  may  be  men- 
tioned prolongation  of  pregnancy.  Jacoby,1  in  reviewing  6,976  labours, 
found  that  in  8*7  per  cent,  the  foetus  weighed  4,000  or  more  grammes; 
20  per  cent,  were  primiparse,  10  per  cent,  women  who  had  more  than 
one  child,  and  9'5  per  cent,  women  who  had  borne  several  children. 
In  9-4  per  cent,  gestation  was  prolonged  beyond  300  days,  and  in 
1 69  per  cent,  beyond  280  days. 

The  largest  child  delivered  at  the  Maternity  Hospital  in  recent 
years  weighed  15  pounds.  Craniotomy  and  cleidotomy  had  to  be 
performed.  Sheill2  recorded  a  similar  difficulty  with  one  about  the 
same  size.  If  the  maternal  pelvis  is  roomy,  labour,  although  tedious, 
is  usually  terminated  without  very  great  difficulty ;  but  if  there  is  any 
pelvic  malformation,  no  matter  how  slight,  the  labour  may  be  both 
difficult  and  dangerous,  and  any  of  the  major  operations  may  require 
to  be  performed.  As  I  have  mentioned  elsewhere,  rachitic  mothers 
have  often  relatively  large  children. 

The  head  of  the  child  causes,  as  a  rule,  the  most  trouble,  for,  apart 
altogether  from  its  size,  the  bones  are  often  unduly  ossified,  and  so 
the  head  does  not  mould  well.  Not  infrequently,  however,  the 
shoulder  girdle  is  the  part  of  the  foetus  which  has  the  greatest 
difficulty  in  passing  through  the  pelvis. 

1  Archiv  f.  Gijn.,  Bd.  lxxiv.,  Heft  3.,  p.  556. 

2  Dub.  Journ.  Med.  Sciences,  July,  1905. 

97  7 


98 


OPERATIVE  MIDWIFERY 


General  Foetal  Dropsy  (Fig.  55)  occasionally  may  cause  con- 
siderable dystocia.  Some  time  ago  in  the  Maternity  Hospital  I  had 
a  case  under  my  care,  and  although  the  delivery  was  not  extremely 
difficult,  it  was  somewhat  trouhlesome,  for  the  limhs  tore  off  whenever 

any  traction  was  made  upon  them. 


Fig.  55. — General  Fcetal  Dropsy. 
(From  a  photograph  of  a  case  in  the  practice  of  Dr.  -lames  Dmil<>]>.) 

A  case  of  this  kind  was  recently  reported  by  Walther '  where  there 
was  considerable  difficulty  in  getting  the  second  twin  away,  as  the 
limbs  came  off  with  the  slightest  traction,  and,  even  although  the 
tissues  were  torn,  little  fluid  escaped. 

Ballantyne,- summing  up  the  histories  of  the  labours  in  such  cases, 

1  Frommel'fl  '  Jahresbericht  iiber  Geb.  u.  ti.yn.,'  1904,  p.  887. 
8  'Antenatal  Pathology  and  Hygiene,' p.  290. 


MALFORMATION  OP  THE  FGETUS  99 

writes  :  '  The  birth  of  a  dropsical  infant  was,  if  near  the  full  term,  a 
tedious  and  often  an  instrumental  matter.  Abnormal  presentations 
were  unusually  common.  The  delay  in  labour  was  sometimes 
overcome  by  the  natural  efforts  and  sometimes  by  manual  or 
instrumental  traction  ;  but  in  certain  instances  the  procedures 
which  were  finally  adopted  before  birth  (in  fragments)  was  effected 
reached  the  utmost  limits  of  embryulcia,  evisceration,  disruption, 
and  dilaceration.  In  some  cases  the  medical  attendant  seems  to 
have  lost  all  nerve,  as  first  one  limb  and  then  another,  and  then 
a  fragment  of  the  trunk  or  the  head,  was  dragged  to  light  from 
the  maternal  passages.  When,  however,  the  fcetal  abdomen,  being 
within  reach,  was  tapped,  it  was  seldom  found  necessary  to  resort  to 
such  embryoclastic  procedures.  The  third  stage  of  labour  was  often 
rendered  somewhat  difficult  on  account  of  the  large  size  and  dropsical 
state  of  the  placenta,  and  by  reason  of  uterine  inertia  due  to  delay  in 
the  earlier  stages.  The  puerperia,  it  is  noteworthy,  were  generally 
quite  normal ;  in  fact,  the  rapid  disappearance  of  many  of  the 
maternal  symptoms  immediately  after  the  emptying  of  the  uterus 
suggested  the  conclusion  that  the  fcetal  condition  was  often  the  cause 
rather  than  the  result  of  the  mother's  ill-health.' 

LOCALIZED  ENLARGEMENT  OF  THE  FOETUS. 

Hydrocephalus. — Amongst  the  enlargements  of  the  fcetal  head 
causing  dystocia  the  most  important  is  hydrocephalus,  a  malformation 
which  is  by  no  means  uncommon  (1  in  1,000),  and  which,  by  reason 
of  the  fact  that  it  is  so  easily  and  so  often  overlooked,  is  frequently 
accompanied  by  very  serious  consequences  to  the  mother.  In  this 
condition  the  ventricles  are  distended  with  fluid,  and  according  to  the 
amount  of  fluid  the  brain  tissue  is  thinned  oiat  and  destroyed.  The 
quantity  of  fluid  contained  in  a  hydrocephalic  sac  may  be  as  much  as 
17  to  20  pints  (10  to  12  litres),  and  the  circumference  of  the  head  may 
measure  as  much  as  30  inches  (75  centimetres)  in  extreme  cases.  The 
base  of  the  skull  and  the  face  bones  are  well  formed,  although  small, 
but  those  of  the  vault  are  very  much  separated,  and  although  not 
always,  still  very  frequently,  defectively  ossified.  The  trunk  and 
limbs  are  usually  small,  and  other  abnormalities,  such  as  spina  bifida, 
talipes,  etc.,  are  not  uncommon. 

A  history  of  the  previous  birth  of  malformed  children  may  some- 
times be  obtained. 

The  condition,  as  I  have  said,  is  not  as  a  rule  diagnosed  until 
labour  has  been  in  progress  for  some  time  ;l  indeed,  often  not  until 

1  Hammerschlag,  Mbnatssch.  f.  Geb.  u.  Gyn.,  Bd.  xxvii.,  Heft  4. 


100  OPERATIVE  MIJAYlI'Kn 

the  accoucheur  has  failed  to  deliver  the  fore-coming  head  with  forceps 
or  the  after-coming  head  by  traction.  That  is  the  reason  why  rupture 
of  the  uterus  occurs  in  somewhere  about  1-  per  cent,  of  cases.  The 
child  almost  invariably  presents  by  the  head  or  breech,  transverse 
presentations  being  very  rare  indeed. 

Breech  presentations  an  very  common  (25  per  cent.),  and  us  the 
diagnosis  of  the  condition  is  most  difficult  in  such  cases,  I  will  speak 
of  them  first.  Theoretically,  by  abdominal  palpation  the  enlarged 
and  elastic  head  should  be  felt  at  the  fundus,  and  without  doubt  in 
some  cases  this  has  been  done.  It  is  seldom,  however,  that  even 
the  most  alert  accoucheur  makes  this  out,  for  prior  to  rupture  of 
the  membranes  palpation  of  the  head  is  difficult,  because  of  the 
liquor  amnii  being  often  excessive;  while  after  rupture  the  fatal 
parts  cannot  be  defined,  because  the  head  and  the  rest  of  the- 
body  are  so  pressed  together,  and  the  lower  segment  is  so  tensely 
distended. 

It  may  be  assumed,  therefore,  that  even  with  the  highly  ex- 
perienced, the  condition  will  be  but  rarely  recognized  until  the  after- 
coming  head  has  to  be  delivered  (Fig.  5(5).  But  if  it  is  excusable 
for  the  accoucheur  to  overlook  the  condition  prior  to  this  time,  it  i- 
quite  reprehensible  for  him  to  do  so  later.  It  is  true  that  the  base  of 
the  hydrocephalic  skull  is  well  formed  and  ossified,  and  that  if  the 
fingers  be  passed  along  the  trunk,  with  the  object  of  getting  them 
into  the  mouth  of  the  child  to  aid  its  delivery,  he  may  feel  nothing  of 
the  enlarged  head,  but  he  should  feel  at  once  with  his  first  traction 
effort  that  the  head  is  too  large  to  pass  the  brim.  Especially  should 
he  be  surprised  at  any  difficulty  when  he  looks  at  the  child,  usually 
puny  and  ill-nourished,  and  sometimes  with  a  spina  bifida  or  other 
malformation.  Besides,  the  uterine  swelling  above  the  pubes  is  still 
of  large  dimensions. 

The  mischief  is  done  just  at  this  stage  ;  the  accoucheur  pulls,  and 
whoever  is  assisting  presses  on  the  uterus  above,  with  the  result  that 
the  uterus  ruptures.  He  has  again  made  the  fatal  mistake  of  trying 
to  deliver  by  force.  His  first  failure  to  effect  delivery  should  have 
raised  in  his  mind  the  possibility  of  the  condition  of  hydro- 
cephalus being  the  cause  of  the  difficulty.  The  only  cases  in  which 
there  is  any  excuse  for  the  mistake  are  those  where,  in  addition  to 
the  enlarged  head,  there  is  pelvic  deformity,  to  which  he  attributes  all 
the  difficulty.  With  such  he  will  be  guided  to  the  correct  nature  of 
the  condition  by  appreciating  the  large  swelling  present  above  the 
pelvic  brim. 

When  the  foetus  affected  by  hydrocephalus  presents  by  ///<■  head, 
the   recognition   of   the   condition   is   easier.     Abdominal   palpation,. 


4l\fl. 


FlG.  ">ti. — Hydrocephalus,  showing  how  the  After  coming  Head  is  caught  at  the 
Pelvic  Brim.     (After  Bunini.) 


102  OPERATIVE  MIDWIFERY 

even  with  this  presentation,  does  not  always  ^rive  as  much  informa- 
tion as  one  might  expect.  The  lower  part  of  the  uterus  i.~  unduly 
distended,  and  the  large  head  is  freely  movable:  bnt,  owing  to  the  fact 
i  hat  the  uterus  so  tensely  grasps  the  head,  the  latter  cannot  be  defined. 
Still,  the  condition  is  overlooked  often,  not  because  of  its  obscurity,  but 
because  the  examination  is  made  hurriedly. 

The  presenting  part,  being  high,  is  difficult  to  reach  from  the 
vagina,  although  I  once  saw  a  case  where,  the  child  being  dead,  a 
portion  of  the  lax  head  projected  down  into  the  cavity,  and  felt 
exactly  like  a  large  caput  succedaneum.  Others  have  mistaken  a 
similar  condition  for  the  bag  of  membranes.  In  most  cases  one  can 
feel  the  gaping  sutures  and  fontanelles,  and  although  a  caput  succe- 
daneum might  obscure  them,  it  is  long  in  forming  in  this  condition. 
A  crackling  sensation  on  pressing  the  head  is  mentioned  as  being 
appreciable  sometimes. 

The  prognosis  for  the  mother,  if  the  condition  is  recognized  and 
suitably  treated,  is  not  serious.  Unfortunately,  however,  the  con- 
dition is  often  overlooked,  and  many  fatal  attempts  at  delivery  are 
made  before  the  true  nature  of  the  complication  is  appreciated.  As 
a  result,  bruises  and  tears  of  the  soft  parts,  with  subsequent  septic 
manifestations,  are  not  uncommon.  Rupture  of  the  uterus  occurs  in 
some  12  to  15  per  cent,  of  cases.  Keith  found  it  occurred  1(5  times 
in  74  cases  ;  and  in  159  cases  reviewed  by  Hohl,  Schuchard,  and  Veit, 
21  ruptures  were  observed.  In  my  own  17  cases  of  rupture  of  uterus 
hydrocephalus  was  present  in  2.  Although,  as  I  have  said,  the 
accoucheur  is  usually  to  blame  for  this,  it  sometimes  happens  that 
he  is  not,  for  the  rupture  may  be  spontaneous,  and  may  even  occur 
early  in  labour,  as  recorded  cases  illustrate. 

Another  danger  to  the  parturient  is  post-part nm  haemorrhage,  the 
result  of  the  overdistension  of  the  lower  segment  and  the  feeble 
retractility  and  contractility  of  the  uterus. 

Unfortunately,  therefore,  the  maternal  mortality  is  still  very  high, 
and  is  certainly  not  below  12  per  cent.,  although,  taking  recent  cases, 
such  as  those  recorded  by  Hoffman  and  Bertino,-  it  works  out  at 
G-6  per  cent.     My  own  results  are  one  in  six  (16  per  cent.). 

In  certain  cases,  where  the  hydrocephalus  is  slight,  delivery  may 
be  spontaneous  or  easily  terminated  by  forceps  or  by  traction  on  the 
lower  limbs  of  the  child.  In  such  cases  the  condition  will  be  appre- 
ciated only  after  the  birth  of  the  child.  Even  with  a  dead  child, 
where  the  head  is  of  some  size,  spontaneous  delivery  may  result 
because  of  the  laxness  of  the  hydrocephalus.  Rupture  of  the  sac 
has  occasionally  occurred,  the  whole  scalp  giving  way;  but  more 
1  WinekePs  '  Hundbueh  der  Geburtshulfe,'  Bd.  ii.,  Teil  ill.,  p.  1646. 


MALFORMATION  OF  THE  F<KTUS  103 

commonly  the  fluid  is  effused  into  the  cellular  tissue  only,  and  extends 
down  over  the  neck  and  shoulders  of  the  child. 

Such  terminations,  however,  do  not  affect  the  treatment,  which 
must  be  to  remove  the  fluid  as  soon  as  the  condition  is  appreciated 
and  the  operation  is  possible. 

The  first  question  which  naturally  occurs  to  one  is,  How  far 
should  the  child's  life  be  considered  in  this  condition  ?  There  are  a 
few  cases  where  the  children  have  remained  alive  for  some  little  time. 
But  if  one  looks  at  the  figures  given  by  Kleinhans1  one  sees  how  hope- 
less the  condition  is,  for,  taking  271  cases  the  different  authorities 
mention,  although  a  few  children  lived  for  weeks,  there  is  only 
one  definite  case  of  cure.  Modern  French  writers  express  themselves 
very  decidedly.  Budin'2  says  :  '  A  supposer  qu'ils  survivent  affliges  ou 
non  d'autres  deformations,  ils  sont  atteints  d'impotence  cerebrale  et 
ne  peuvent  guere  etre  que  des  cretins  ou  des  idiots ';  and  Piibemont- 
Dessaignes  and  Lepage3  remark  :  '  S'il  survit  et  s'il  atteint  l'age  d'un 
an,  l'hydrocephale  presente  habituellement  tous  les  signes  de  l'idiote, 
de  telle  sorte  qu'au  point  de  vue  de  la  conduite  a  tenir  pendant 
l'accouchemente,  la  vie  du  foetus  ne  doit  pas  entrer  en  ligne  compte.' 

To  tap  the  head  and  inject  a  quantity  of  fluid  equal  to  the  amount 
removed,  and  so  possibly  save  the  child  for  a  few  months,  is  quite 
quixotic.  If  the  head  is  of  such  a  size  as  to  necessitate  tapping,  the 
child  should  be  destroyed  by  the  operator  stirring  up  the  brain  with 
the  perforator. 

The  fluid  in  the  ventricles  may  be  withdrawn  by  a  trocar,  or  by 
making  an  opening  with  the  perforator.  Any  sharp  instrument  does 
for  this  purpose,  and  twice  I  have  employed  a  pair  of  sharp-pointed 
scissors.  The  best  instrument  is,  of  course,  the  perforator.  The 
perforation  of  both  the  fore-coming  and  after-coming  head  is  very 
simple.  In  the  former  presentation  the  instrument  is  pushed  through 
one  of  the  gaping  sutures,  while  in  the  latter  it  is  pushed  through  the 
skull  in  the  neighbourhood  of  the  postero-lateral  fontanelle.  The 
manner  of  employing  the  perforator  is  detailed  fully  in  the  chapter  on 
Craniotomy  (Chapter  XXIX.). 

The  delivery  of  the  child  in  breech  presentations  is  readily  accom- 
plished by  making  traction  on  the  body.  When  the  presentation  is 
the  head,  however,  unless  the  case  is  left  to  Nature,  one  must  have 
recourse  to  the  cephalotribe  or  forceps.  Usually  a  sufficient  hold  can 
be  obtained  with  the  forceps,  but  should  that  not  be  possible,  the 
cephalotribe  must  be  employed. 

1  Winckel's  '  Handbuch,'  Bd.  ii.,  Teil  iii.,  p.  1646. 

-  Tarnier  and  Budin,  '  Traite  de  l'Art  des  Accouchenients,'  1901,  tome  iv..  p.  28. 

3  '  Precis  d'Obst&rique,'  190-4,  p.  1008. 


104 


ol'KHATIYK  MinW'IFKIlY 


Quite  recently  Ballantyne1  drew  attention  to  the  advantage  of  with- 
drawing the  fluid  by  spinal  tapping.  This  treatment  was  suggested  hy 
Van  Hueval,  and  first  carried  out  hy  Tarnier  in  18<;k.  Certainly  it  is 
a  very  simple  method,  especially  if  there  is  a  spina  bifida.  After 
opening  into  the  spinal  canal,  a  silver  or  gum  elastic  catheter  is  passed 
into  it  and  pushed  up  into  the  cranium  (Fig.  57). 

As  there  is  danger  of  post-partum  haemorrhage  with  this  com- 
plication, it  is  advisable  to  have  everything  ready  for  such  an  accident. 


Fig, 


57. — Removal  of  the  Fluid  in  Hydrocephalus  by  Spinal  Tapping. 

(Tarnier  and  Budin.) 


In  cases  of  cranial  presentations,  if  the  hydrocephalus  is  detected 
early  in  labour,  before  the  os  is  dilated,  the  head  should  be  punctured 
and  the  further  progress  of  the  labour  left  to  Nature. 

Meningocele  and  Encephaloeele.  Such  localized  tumours  of  the 
head  are  occasionally  encountered.  The  accompanying  illustration 
(Fig.  58)  of  a  fietus,  delivered  at  the  .Maternity  Hospital,  is  an 
example  of  the  latter.     They  appear  along  the  sutures,  but  especially 

1  Edin.  Obstet.  Trans.,  190;"),  vol.  xxx.,  p.  20. 


MALFORMATION  OF  THE  FfKTUS 


105 


it  the  fontanelles,  and  more  particularly  the  posterior  fontanelle. 
They  rarely  cause  trouble  at  birth,  for,  although  the  sac  is  sometimes 
}f  large  size,  it  is  lax,  and  becomes  stretched  or  flattened  out  during 
labour.  They  frequently,  however,  as  in  the  case  illustrated,  cause 
alteration  in  attitude  and  position  of  the  fct'tal  head.  Facial  presenta- 
ions  are  specially  common. 

The  condition  is  often  not  recognized  until  after  the  birth  of  the  child, 
rheoretically,  the  swelling  might  be  appreciated  by  abdominal  palpa- 


Fig.  58.— Encephalocele.     (Author's  Collection.) 


tion,  but  it  is  usually  so  placed  that  it  is  difficult  to  define.  With  the 
fore-coming  head  the  condition  has  been  mistaken  for  a  double 
monster,  twins,  and  a  cystic  tumour  of  uterus  or  ovary.  In  all  cases 
of  doubt  the  hand  should  be  passed  into  the  uterus  and  a  careful 
investigation  made. 

If  spontaneous  delivery  does  not  occur,  the  head  can  usually  be 
delivered  by  forceps,  but  should  there  be  any  difficulty  the  sac  must 
be  tapped.  In  cases  of  this  group,  if  the  tumour  is  a  meningocele 
and  has  a  narrow  stalk,  a  few  of  the  children  may  be  cured  by  opera- 


106  OPERATIVE  Ml  DWIPERI 

tion,  or  sometin  without  interference  if  the  Btalk  of  the 

shrivels  up.  Eence  the  reason  for  Bimply  tapping.  Most  of  tin- 
children  are  born  dead  or  die  Bhortly  after  birth.  It  is  curious  that, 
although  compression  of  the  tumour  after  the  child  is  horn  ol 
causes  convulsions,  this  has  not  been  observed  during  labour.  The 
death  of  the  child,  however,  must  sometimes  he  the  result  of  com- 
pression during  labour,  for  many  of  the  children  have  evidently  died 
very  shortly  before  birth. 

Dystocia  from  Large  Shoulder-Girdle,  Tumours  of  Neck  and 
Thorax. — During  or  after  the  escape  of  the  head,  the  descent  of  the 
child  may  be  interfered  with  by  reason  of  the  size  of  the  shoulder- 
girdle  or  the  presence  of  tumours  about  the  neck  or  thorax. 

Dystocia  caused  by  a  large  sJioidder-girdle  is  the  most  frequent  of j 
these  conditions.  In  most  cases  the  whole  child  is  of  unusual  size, 
and  weighs  sometimes  11  or  12  pounds.  Unusual  size  of  the  head 
and  thickness  of  the  neck  should  lead  one  to  suspect  the  shoulders  as 
being  the  cause  of  the  dystocia,  if  there  is  any  difficulty  in  delivering 
them.  I  have  once  or  twice  seen  the  trunk  proportionately  larger 
than  the  head,  and  it  has  been  remarked  that  the  anencephalic  foetus 
has  often  an  unusually  large  body. 

Difficulty  with  the  shoulders  after  the  birth  of  the  head  can  only 
arise  from  the  shoulders  getting  caught  by  reason  of  their  size  andi 
position  or  by  reason  of  pelvic  deformity.  It  is  not  conceivable  that 
at  this  stage  Bandl's  ring  could  be  the  obstructing  cause.  I  have 
once  or  twice  found  the  cord  wound  round  the  neck,  and  no  doubt | 
actual  or  relative  shortness  of  the  cord  may  hinder  the  delivery 
the  child.  The  differential  diagnosis  between  large  shoulders  aim 
short  cord  will  usually  not  be  difficult,  and  in  all  cases  of  doubt 
should  be  arrived  at  by  a  thorough  exploration  with  the  hand  in  the] 
vagina. 

In  the  slighter  degrees  of  difficulty  with  the  shoulders  it  may  be 
found  that  the  cause  is  a  failure  of  the  shoulders  to  rotate.     Should! 
that  be  the  case,  the  hand  must  be  passed  along  the  back  of  the  neck 
over  the  shoulder,  and  the  rotation  aided. 

When  decided  difficulty  arises  with  the  fore-coming  shoulders,  the 
course  to  pursue  depends  upon  whether  the  child  is  living  or  not. 
If  it  is  dead  no  further  attempts  at  delivery  should  he  made,  both; 
clavicles    should    be    divided.      This   operation   (cleidotomy)  is  fully 
described  in  Chapter  XXIX.    I  have  always  succeeded  in  delivering  the  j 
child  by  this  means.     It  has  sometimes  happened  that  the  operator  has 
removed  the  head  and  then  separated  the  anus  before  he  could  bring 
the  trunk  down,  and  I  cannot  see  any  greal  objection  to  such  treat- j 
ment,  although  it  is  generally  considered  inadvisable,  seeing  that  one 


MALFORMATION  OF  THE  FOETUS  107 

oses  the  benefit  of  the  head  for  traction.  Theoretically,  with  the 
iead  away,  however,  any  limb  may  be  brought  down.  Provided  there 
s  no  large  stump  of  neck  left,  the  arm  is  about  as  good  as  the  leg 
or  traction,  except  that  it  is  more  easily  pulled  off.  It  might  be  a 
ittle  awkward  if  one  were  left  with  a  large  trunk  and  both  arms 
emoved.  Therefore,  I  think  it  wisest  to  divide  the  clavicle,  and,  should 
he  shoulder  still  not  come  down,  to  pass  a  sharp  hook  into  one  axilla, 
>referab'ly  the  anterior. 

With  a  living  child  whose  shoulders  are  so  large  that  they  prevent 
he  descent  of  the  trunk,  one  is  in  a  very  awkward  predicament. 
Biter  having  failed  to  effect  delivery  by  means  of  a  finger  inserted 
nto  the  armpit,  it  is  safer  to  run  the  risks  of  the  blunt  hook  than 
o  make  extreme  traction  upon  the  neck,  for  the  danger  to  the  child 
>f  such  a  proceeding  is  very  great.  When  the  hook  is  employed,  it 
hould  be  passed  into  the  anterior  axilla,  if  at  all  possible,  for  if  one 
>asses  it  into  the  posterior,  and  the  anterior  is  still  above  the  brim, 
he  latter  will  catch  upon  the  brim,  and  the  delivery  of  the  shoulders 
endered  more  difficult. 

Should  by  any  chance  these  devices  fail,  and  I  actually  encountered 
iuch  a  case  quite  recently,  the  child's  condition  will  have  become 
Jmost  hopeless.  The  clavicles  should  therefore  be  divided,  and  the 
sxtraction  completed  as  if  the  child  were  dead.  It  has  been  suggested 
o  perform  symphysiotomy  ;  but  few,  I  fancy,  would  favour  such  a 
reatment,  as  it  would  increase  the  maternal  mortality,  already  very 
ligh,  without  much  prospect  of  saving  the  child  already  endangered. 

A  very  similar  dystocia  —  viz.,  a  difficulty  in  extracting  the 
ihoulders  or  even  the  head — may  be  caused  by  tumours  of  the  neck 
on  I  by  hydrothorax.  Cystic  and  solid  tumours  of  the  neck  are  rarely 
)f  a  size  sufficient  to  cause  obstruction.  The  one  figured  in  Winckel's 
Text-book'1  is  the  largest  I  know  of.  One  recently  described  by 
lewetson2  in  great  detail  is  through  the  kindness  of  the  author 
■eproduced  here  (Fig.  59). 

Distension  of  the  foetal  thorax  is  of  great  rarity.  Winckel3  men- 
ions  seven  cases.  Hydrothorax  is  invariably  accompanied  by  ascites. 
3allantyne4  refers  to  such  a  case  reported  by  Hardouin  and  Moreau. 
f  there  is  much  distension  of  the  chest,  the  shoulders  will  always 
tave  difficulty  in  engaging,  and  perforation  of  the  chest  is  necessaiy. 

Tumours  connected  with  the  Abdomen  and  Pelvis.  —  The 
lext  malformations  we  must  consider  are  those  connected  with  the 
-bdomen  and  pelvis.      In  certain  cases  these  conditions  may  even 

1  Edgar's  translation,  1890,  p.  430. 

2  Journ.  Obstet.  and  Gyn.  Brit.  Empire,  1903,  vol.  i\\,  p.  :!■"'■",. 

3  Op.  cit.,  p.  434.  4  Op.  cit.,  p.  362. 


Fig.  59.— Congenital  Adenomatous  Bronchocele.     (Hewetson.) 


MALFORMATION  OF  THE  FOETUS 


10!> 


tinder  the  engagement  of  the  shoulders.     As  a  rule,  a  diagnosis  is 
>nly  possible  if  the  hand  is  passed  into  the  vagina. 


Fig.  60.— Foetal  Ascites.     (Ballantyue.) 

Distension  of  the  abdomen  from  ascites  (Fig.  60)  and  tumours  of 
the  spleen,  liver,  testicles,  ovaries,  kidneys  (Fig.  61),  bladder,  although 


110  OPERATIVE  MIDWIFERY 

rare,  is  not  very  uncommon.  Each  of  these  tumours  is  of  pathologic! 
interest,  but  unfortunately  they  cannot  be  considered  here.  FroB 
the  obstetric  standpoint  they  all  present  the  same  feature.  The  difl 
tended  abdomen  prevents  the  descent  of  the  foetus. 


I-,,.    61.— Congeoitally  Enlarged  Kidneys  (Natural  Size  .     (Ballantyne.) 

If  the  presentation  is  cranial,  unless  the  abdominal  distension  is 
extreme,  the  shoulders  can  usually  be  delivered ;  the  trouble  is  in 
♦  •xtracting  the  trunk.  In  these  cases  the  diagnosis  is  simple,  for  the 
trunk  of  the  child  should  always  pass  through  the  maternal  pelvis 


MALFORMATION  OF  THE  FCKTFS 


111 


iixsily.  When,  however,  the  shoulders  also  refuse  to  descend,  there  is 
,  little  more  difficulty  in  appreciating  the  cause  of  the  dystocia.  The 
inusual  distension  of  the  mother's  abdomen  may  arrest  attention,  but 
ometimes  the  hand  has  to  be  passed  into  the  uterus  before  a  diagnosis 
an  be  made.  I  had  an  illustration  of  this  recently  in  a  case  of 
xtrerue  ascites. 

Should  the  child  present  by  the  breech,  one  or  both  legs  may  be 
>ro light  down,  but  further  delivery  is  impossible.     The  other  con- 


\L> 


Fig.   62. — Enormously  Large  Congenital  Sacral  Tumour. 
(Museum  of  the  Pathological  Institute,  Glasgow  University.) 


iitions  which  may  give  rise  to  a  similar  difficulty  are  tumours  of  the 
acrum  and  the  arrest  of  the  child  by  the  retraction  ring.  The  latter 
ondition — a  very  interesting  one — is  referred  to  elsewhere.  Here, 
-gain,  the  passage  of  the  hand  into  the  uterus  alone  will  clear 
natters  up. 

In  cases  of  distension  of  the  foetal  abdomen,  the  bulk  of  the  child 
an  usually  be  sufficiently  diminished  by  withdrawing  the  fluid  by  an 
ispirator,  as  most  of  the  conditions  encountered  are  cystic.  It  some- 
imes  happens,  however,  when  the  tumours  are  connected  with  liver, 


112  OPERATIVE  MlbYYIFKKY 

spleen,  or  kidney,  that  they  cannot  be  sufficiently  lessened  by  this 
simple  device,  and  so  a  large  abdominal  opening  has  to  be  made,  and 
the  tumours  broken  up  and  removed  by  the  hand.  In  cases  of  asci 
the  foetua  is  usually  born  dead,  but  when  the  other  tumours  mentk>. 
are  present  it  may  be  born  alive.  Should,  therefore,  any  evisceration 
have  been  necessary  in  cases  of  breech  presentation  the  after-coming 
head  should  be  perforated. 

Sacral  congenital  tumours  obstructing  labour  (Pig.  62)  usually 
give  most  trouble  when  the  child  presents  by  the  breech.  With  the 
fore-coming  head,  the  legs  and  tumour  slip  through  the  pelvis  more 
easily.  In  several  eases — one,  for  example,  recently  recorded  by 
Hewetson1  and  one  by  Frommel2 — the  child  could  only  be  extracted 
after  the  tumour  was  broken  up.  In  the  former  case  the  child 
presented  by  the  breech,  and  in  the  latter  by  the  head. 

The  diagnosis  of  the  condition  when  the  tumour  presents  may  be 
very  difficult,  and  is  most  likely  to  be  confused  with  a  submucous 
mvoma.  A-  I  have  repeatedly  said,  however,  in  all  cases  of  doubt  a 
manual  exploration  of  the  uterus  should  be  made  under  anaesthesia. 

1  Journ.  Obstet.  and  Gyn.  Brit.  Empire,  1903,  vol.  iii.,  p.  203. 

2  •  Jahresberieht,  iiber  Geb.  u.  Gyn..'  1904,  vol.  xviii..  p.  886 


CHAPTER  VIII 

DYSTOCIA  THE    RESULT   OF  ABNORMALITIES   AFFECTING   THE 

FCETUS— Continued 


Presence  of  More  than  One  Foetus. 

We  cannot  discuss  here  the  etiology  or  anatomy  of  plural  pregnancy, 
the  most  interesting  questions  in  connexion  "with  this  subject,  nor 
can  we  consider  the  effect  the  former  has  upon  such  complications  as 
eclampsia,  toxremia.  etc.  We  are  concerned  with  the  condition  only 
as  it  affects  labour. 

The  ease  with  which  the  diagnosis  of  plural  pregnancy  can  be 
made  depends  very  much 
on  how  the  ova  are  placed. 
In  the  cases  where  they 
lie  side  by  side  (Fig.  63), 
or  in  the  rare  condition  in 
which  the  one  is  above  the 
other  (Fig.  64),  it  is  not 
difficult.  When,  however, 
both  lie  longitudinally  and 
are  placed  the  one  behind 
the  other  (Fig.  65),  there 
is,  as  a  rule,  considerable 
difficulty. 

As  regards  the  diag- 
nosis, absolutely  no  reliance 
should  be  placed  upon  such 
subjective  symptoms  as  a 
feeling  of  unusual  size,  the 
sensation  of  a  great  deal 
of  foetal  movement,  etc. ; 
similarly,  in  palpating  the 

abdomen,  one  must  not  conclude  that  there  are  twins  simply  because 
of  the  size  of  the  abdomen  or  the  apparently  unusual  number  of 
limbs.     I  have  been   so  often  deceived  that  I  only  diagnose  plural 

113  8 


Fig.  63. — Twins  lying  Side  by  Side. 


Ill 


OI'FJtATIVK  MII>WI!T.l;Y 


Fig.  64.— Twins  lying  One  Above  the  Other. 


pregnancy  when  I  feel  two  foetal  heads.     Two  breeches  should  make 
it  quite  as  conclusive :  but  the  breech  is  much  more  difficult  to  define, 

and  I  definitely  decide  upon 
plural  pregnancy  only  when 
1  feel  two  heads. 

I  have  purposely  not 
referred  to  the  outline  of 
the  abdominal  swelling  in 
the  case  of  twins,  for  I 
have  not  found  it  of  great 
service.  "Without  doubt, 
especially  if  the  children 
are  lying  side  by  side, 
a  sulcus  may  mark  the 
division  between  the  two 
sacs,  but  as  often  as  not 
no  such  dividing  mark  is 
present.  Very  much  the 
same  applies  to  the  foetal 
heart  sounds.  It  is  fre- 
quently stated  that  hear- 
ing these  sounds  over  two 
areas,  separated  by  an  area 
in  which  they  cannot  be 
heard,  should  lead  one  to 
suspect  plural  pregnancy. 
It  should  not,  however,  do 
more,  for  I  have  several 
times  observed  the  same 
when  there  was  only  one 
foetus.  To  be  absolutely 
certain  that  there  are  two 
fcetal  hearts  beating,  the 
accoucheur  must  make  out 
the  heart  sounds  to  be  of 
different  rhythms  over  the 
two  areas.  They  should 
therefore  be  counted  simul- 
taneously by  two  observers, 
for  it  is  surprising  how 
quickly,  and  often  after  the 
slightest  movement,  the  foetal  heart  rhythm  becomes  altered. 

Lastly,  the  feeling  of  two  distinct  sacs  through  the  os  is  only 


FlG.  65. — Twins  lying  One  in  Front  of  the  Other. 


PRESENCE  OF  MORE  THAN  ONE  F(ETUS 


11/ 


possible  where  the  os  is  sufficiently  dilated.  Although  not  infre- 
quently with  plural  pregnancy  the  os  is  dilated  for  some  time  before 
labour,  I  have  only  been  able  to  make  out  this  feature  on  two 
occasions,  and  in  both  the  foetuses  were  lying  side  by  side.  It  is 
stated  that  even  when  they  lie  one  in  front  of  the  other  the  two  sacs 
may  occasionally  be  felt ;  but  I  fancy  that  is  unusual,  for  in  such 
cases  the  one  is  invariably  higher  than  the  other. 

The   relative   frequency   of    the   positions   of    the   foetuses   is   as 
follows  I1 

Total  Cases,  1840  (Leonhard). 


First  child     - 

head  ; 

Second  child     - 

head 

-     38-5 

361 

cent 

»> 

head; 

n 

breech 

-     21-1 

ii 

)> 

breech ; 

)> 

head 

-     14-3 

ii 

>j 

breech ; 

11 

breech 

-     10-7 

ii 

>> 

head  ; 

>' 

transverse 

-       8-3 

ii 

)> 

transverse ; 

)) 

head 

-       0-8 

ii 

)> 

breech  ; 

11 

transverse 

-       4-2 

ii 

,, 

transverse ; 

11 

breech 

-       0-7 

ii 

»> 

transverse ; 

)5 

transverse 

-       09 

ii 

As  regards  the  overlooking  of  plural  pregnancy,  or  diagnosing  it 
when  it  does  not  exist,  both  errors  are  common.  Sometimes  the  co- 
existence of  such  conditions  as  hydramnios,  cystic  tumours,  or  mal- 
formation of  the  uterus  may  confuse  matters,  but  as  a  rule  that  is 
not  the  reason  of  the  mistakes.  Most  generally  they  result  either  from 
simply  overlooking  the  condition  altogether  or  from  basing  a  diagnosis 
on  insufficient  evidence.  As  I  said  before,  I  always  now  withhold  a 
diagnosis  in  a  doubtful  case,  unless  I  can  palpate  from  the  abdomen 
two  foetal  heads  or  can  feel  two  bags  of  membranes  per  vaginam. 

As  a  rule,  the  recognition  of  plural  pregnancy  prior  to  labour  is  a 
matter  of  no  great  practical  importance.  The  exact  state  of  matters 
is  appreciated  after  the  birth  of  the  first  child,  and  that  is  quite 
sufficient.  I  once,  however,  did  find  the  correct  diagnosis  during 
pregnancy  of  importance,  and  others  have  had  a  similar  experience. 
It  was  a  question  of  inducing  labour  in  a  contracted  pelvis  in  which 
the  deformity  was  of  the  medium  variety — viz.,  a  conjugata  vera  of 
about  3}  inches  (7'8  centimetres).  After  a  careful  examination  of  the 
case  and  a  diagnosis  of  twins  I  did  not  induce  labour,  because, 
presumably,  the  children  would  be  smaller  than  usual,  and  so  would 
pass  through  the  pelvis  more  readily.  My  surmise  proved  correct, 
and  the  result  was  highly  satisfactory,  both  children  were  born  alive 
without  any  interference  being  necessary. 

The  effect  of  more  than  one  foetus  being  present  is  generally  to 
1  Strassmann  (Winckel's  '  Handbuch,'  Bd.  L,  Heft  2,  p.  1273). 


116  OPERATIVE  MIDWIFERY 

delay  labour.  The  contractions,  owing  to  the  overdistension  of  the 
uterus,  are  weaker,  and  bearing  down  after  rupture  of  the  membranes 
is  more  feeble.  The  contractions,  too,  are  often  very  painful.  Against, 
and  counteracting  to  some  extent,  these  conditions  is  the  smallness  of 
the  children. 

In  cases  left  absolutely  to  Nature  there  is  not  a  little  delay  between 
the  birth  of  the  two  children.  According  to  Strassmann,  in  seventy 
cases  left  to  Nature  the  average  duration  of  time  between  the  birth  of 
the  two  infants  was  twenty-eight  minutes.  In  thirty-one,  however,  it 
was  only  ten,  and  in  sixteen  it  was  only  fifteen  minutes.  The  longest 
time  was  three  hours.  The  other  extreme  of  many  hours  and  even 
days  intervening  will  be  found  in  the  records  of  a  few  cases  scattered 
throughout  the  relative  literature. 

The  general  rule  is  that  both  placenta;  follow  the  expulsion  of 
the  second  child.  I  have  never  seen  it  otherwise,  and  Strassmann, 
in  a  series  of  476  cases,  found  it  occurred  in  all  except  three  cases. 
When,  however,  there  is  a  very  long  interval  between  the  birth  of 
the  two  children,  it  has  happened  that  the  placenta  of  the  first  has 
remained  in  the  vagina  and  become  septic.  Futh1  has  referred  to 
such  cases,  and  pointed  out  the  dangers  to  mother  and  child. 

Bearing  in  mind  these  few  facts  regarding  the  progress  of  labour 
in  plural  pregnancy,  let  us  consider  the  treatment  which  should  be 
followed. 

Speaking  generally,  labour  should  be  interfered  with  as  little  as 
possible,  and  it  should  never  be  forgotten  that  there  is  always  a  period 
of  uterine  quiet  after  the  first  child  is  born. 

It  may  occasionally  happen  that  rupture  of  the  bag  of  membranes 
of  the  first  child  will  help  matters,  for  it  will  diminish  the  overdisten- 
sion, and  therefore  it  is  sometimes  quite  a  wise  course,  even  before) 
the  os  is  fully  dilated,  to  rupture  the  membranes.  Then,  again, 
the  fact  that  the  contractions  are  often  feebler  than  normal  will  not 
infrequently  compel  one  to  assist  delivery  by  forceps,  or  by  traction  on 
the  lower  limbs.  It  is  inadvisable,  however,  to  perform  version  upon 
the  first  child  unless  there  is  some  coexisting  complication,  such  as; 
placenta  praevia,  for  there  may  be  difficulty  in  extracting  the  after- 
coming  head,  especially  as  suprapubic  pressure  cannot  be  very 
effectively  employed. 

The  first  child  being  born,  and  the  cord  tied  both  distally  and 
proximally,  one  should  wait  for  a  little  time  unless  there  is  some 
indication,  such  as  ha?morrhage,  for  hastening  the  delivery.  If  the 
membranes  do  not  rupture  in  fifteen  or  twenty  minutes,  that  should 
be  done  artificially.  At  the  same  time  the  exact  presentation  ol 
1  Zcnt.f.  Qyn.,  1901,  p.  1055. 


PRESENCE  OF  MORE  THAN  ONE  F(ETUS  117 

he  second  child  should  be  determined,  for  it  occasionally  happens 
hat  after  the  birth  of  the  first  the  second  one  changes  its  position. 
Although  the  change  may  be  for  the  better,  it  is  often  for  the  worse, 
i,  previously  longitudinal  lie  being  converted  into  an  oblique.  The 
nembranes  being  ruptured,  the  second  child  is,  as  a  rule,  soon  ex- 
jelled  ;  if  not,  its  delivery  must  be  completed  by  artificial  means.  It 
s  a  mistake  to  hurry  too  much  the  delivery  of  the  second  child 
vith  forceps,  for  in  grasping  a  head  which  is  still  movable  it  will 
'■ery  often  be  pulled  into  an  unfavourable  position.  If  possible,  then, 
et  the  head  engage  before  applying  the  instrument.  Indeed,  like 
nany  others,  I  consider  it  better  to  employ  version,  for  there  will 
ieldom  be  any  difficulty  in  performing  it,  and,  the  passage  being 
ilready  dilated,  the  second  child  passes  readily,  unless,  of  course,  it  is 
>f  unusual  size. 

It  would  be  quite  out  of  place  to  discuss  further  the  dangers  and 
complications  of  plural  pregnancy.  Everyone  is  aware  that  plural 
pregnancy  throws  a  greater  strain  upon  the  mother,  and  that  such 
complications  as  eclampsia,  toxaemia,  placenta  prsevia,  and  post-partum 
hemorrhage,  are  more  common.  One  can  understand,  therefore,  why 
,he  maternal  mortality  and  morbidity  should  be  higher. 

The  foetal  mortality  is  also  high.  The  fact  that  the  children  are 
50  often  premature,  poorly  developed,  and  malformed ;  that  the 
circulation  in  one  or  both  is  interfered  with  by  the  communication  of 
heir  bloodvessels  and  the  faulty  insertion  of  their  cords ;  and  that 
luring  their  birth  complications  readily  arise,  explains  why  that 
should  be  so. 

Before  leaving  the  subject,  however,  I  must  consider  for  a  moment 
i  most  interesting  accident  which  occasionally  arises  in  connexion 
vith  twin  births — viz.,  '  locking.'  I  have  purposely  kept  it  quite 
ipart  from  my  general  remarks  on  the  management  of  plural  preg- 
lancy  because  it  is  such  an  extremely  rare  occurrence.  According  to 
{.  Braun,  it  only  occurred  once  in  90,000  cases  in  the  two  Vienna 
:liniques.  Personally,  I  have  seen  it  once  in  a  case  of  premature 
abour,  when  both  children  were  small.  The  condition  may  threaten 
when  two  foetal  sacs  appear  together.  In  such  cases  it  is  well  to 
avour  the  delivery  by  rupturing  the  sac  which  contains  the  child 
vith  the  head  presenting,  and  following  upon  that,  to  place  the 
voman,  if  possible,  so  that  the  force  of  gravity  will  tend  to  withdraw 
he  other  child  from  the  pelvic  inlet. 

There  is  here  represented  two  forms  of  '  locking,'  and,  as  can 
>e  seen  at  a  glance,  the  first  locking  of  fore-coming  and  after-coming 
leads  is  much  more  serious  than  the  other  in  which  the  two  fore-coming 
leads  become  impacted. 


IIS 


OPERATIVE  MIDWIFERY 


Taking  the  first  variety  (Fig.  <'•<">>,  where  an  after-coming  head 

becomes  caught  by  the  fore-coming  head   of   the  second  child,  an 
attempt  should  first  of  all  be  made  to  push  up  the  second,  and  under 


/ 


Fig.  66.— Locking  of  After-coming  Head  of  First  Child  with  Fore-coming  Head  ol  - 

(Bumm.) 


deep  anaesthesia  this  may  succeed.  It  did  so  in  a  case  under  my  care. 
Should  that  manceuvre  prove  unsuccessful,  it  is  inadvisable  to  do  as 
has  been  suggested,  even  although  it  has  been  successfully  carried 


LOCKE])  TWINS 


11!) 


out — viz.,  apply  forceps  to  the  fore-coming  head  of  the  second  child. 
The  dangers  to  the  second  child  are  great  and  the  risks  to  the  mother 
not  inconsiderable,  as  she  will,  almost  certainly,  have  her  parturient 
canal    considerably    lacerated.      Consider   the   condition  of   matters. 


Flu.  67. — Locking  of  Two  Fore-coming  Heads. 


The  chances  of  the  first  child  being  saved  are  almost  nil.  It  has 
already  had  its  circulation  seriously  interfered  with,  owing  to  pressure 
upon  its  cord.  The  second  child,  on  the  other  hand,  has  not  yet  had 
its  life  in  the  least  endangered.  Of  course,  if  it  is  known  that  the 
second  child  is  dead,  then  everything  must  be  done  to  try  and  save 


120 


OPERATIVE  MIDWIFKIIY 


the  first;  but  presuming  that  the  second  child  is  living,  the  onl\ 
course  is  to  decapitate  the  first,  apply  forcep3  to  the  head  of  the  second 
child  and  deliver  it,  and,  finally,  remove  the  severed  head  of  the  first 
with  forceps  or  the  cephalotribe. 

As  regards  the  locking  of  two  fore-coming  heads  (Fig.  <">7),  it  is 


Fig.  68. — Locking  of  After-coming  Sead  of  First  Child  with  the  Shonlder  of  the  v 

(Bumin.) 


seldom  of  any  consequence,  for  the  second  can  usually  be  pushed  out 
of  the  way.  Failing  that,  attempts  at  extracting  the  first  with  forceps 
should  be  made,  and  if  that  still  fails,  craniotomy  on  the  first  child 
is  preferable  to  craniotomy  on  the  second,  whose  life  so  far  is  not  at 
all  endangered. 


LOCKED  TWINS  121 

A  most  hopeless  condition  is  that  in  which  an  after-coming  head 
,nd  a  shoulder  with  a  prolapsed  arm  become  impacted  (Fig.  68). 
3audelocque  accomplished  delivery  by  decapitating  the  first  child  and 
Bfrforming  version  on  the  second,  which  would  certainly  appear  to  be 
he  best  course.  Should  it  be  quite  impossible  to  reach  the  neck  of 
ither  child.  Cesarean  section  might  be  the  only  alternative. 


CHAPTElt  IX 

DYSTOCIA  THE  RESULT  OF  ABNORMALITIES  AFFECTING 
THE  FCETUS— Continued 

Double  Monsters. 

By  J.  W.  BALLANTYNK,  M.D.,  F.B.S.Ed.,  etc. 

Few  medical  men  are  called  upon  to  conduct  a  case  of  labour  in 
which  the  product  consists  of  a  double  monster,  and  even  obstetricians 
of  considerable  experience  will  see  no  more  than  two  or  three  confine- 
ments so  complicated  in  a  lifetime.  Nevertheless,  any  practitioner 
may  any  day  find  himself  face  to  face  with  such  an  obstetric 
emergency,  either  in  his  own  or  in  a  brother  practitioner's  practice; 
and  it  is,  therefore,  necessary  for  him  to  know  what  has  been  the 
usual  history  of  such  cases,  and  in  what  way  the  difficulty  in  delivery 
can  best  be  overcome. 

It  is  safe  to  say  that  in  the  past  cases  of  difficult  labour,  in  which 
the  cause  of  the  difficulty  was  the  presence  of  united  twins  in  the 
uterus,  have  generally  been  dealt  with  without  any  consideration  for 
the  life  of  the  double  monster.  As  a  matter  of  fact,  the  only  cases 
(two  in  number)  with  which  the  writer  has  had  to  do  were  ended 
after  great  difficulty  by  a  sort  of  general  dismemberment  of  the] 
foetuses.  There  are,  however,  certain  circumstances  which  may  now 
make  it  necessary  for  us  to  revise  our  views  regarding  such  a  mode 
of  obstetric  interference.  In  the  first  place,  the  profession  regards 
with  very  different  feelings  the  operation  of  craniotomy  on  the  living 
foetus,  and  is  striving  to  substitute  methods  of  interference,  such  as 
•Cesarean  section,  symphysiotomy,  and  the  induction  of  premature 
labour,  which  shall  give  a  chance  of  survival  to  the  infant.  The  life 
of  united  twins  may  not,  perhaps,  appear  to  have  a  high  value  :  but  it 
is  a  fact  that  some  individuals  thus  congenitally  fused  have  survived 
for  a  number  of  years,  and  not  unhappily.  The  Siamese  twins 
constitute  an  instance  of  this,  for  these  brothers  lived  from  1811  till 
1874,  and  begat  normal  children.  In  the  second  place,  Caesarean 
section  can  now  be  performed   with  a  much  lower  mortality  than 

1-2-2 


DOUBLE  MONSTERS  L23 

formerly,  and  gives  an  alternative  method  of  delivery  in  cases  which 
used  always  to  be  terminated  by  embryulcia.  In  the  third  place, 
united  twins  are  not  now  condemned  to  pass  their  lifetime  so  fused 
together,  for  modern  surgery  has  attempted,  and  in  one  or  two 
instances  has  carried  out  with  partial  success,  the  separation  of  the 
two  bodies.  At  the  same  time,  while  these  new  circumstances  ought 
to  make  us  take  a  different  view  of  our  responsibilities  in  the  treat- 
ment of  labours  complicated  by  the  presence  of  double  monsters,  it  is 
doubtful  whether  it  will  be  found  possible  as  yet  to  apply  them  to  the 
actual  obstetric  management  of  cases.  There  is  still  the  difficulty  of 
the  ante-partum  diagnosis  of  the  existence  in  utero  of  such  a  mon- 
strosity. Although  it  may  be  possible  for  the  more  skilful  diag- 
nostician to  suspect  abnormalities  of  the  unborn  infant  as  a  result 
of  his  palpation  of  the  uterus,  it  is  the  general  rule  that  the 
malformation  is  not  recognized  till  labour  is  in  the  second  stage,  and 
till,  therefore,  induction  of  premature  labour  is  out  of  the  question, 
and  Csesarean  section  can  only  be  performed  under  disadvantageous 
conditions.  It  must  be  borne  in  mind  that  the  antenatal  diagnosis  of 
twins  can  rarely  be  made  with  certainty,  the  obstetrician  being  forced 
to  content  himself  with  intranatal  recognition  of  this  complication  of 
labour.  And  I  know  of  no  way  in  which  the  nature  of  the  twins  can 
be  foretold  before  their  birth,  for  even  if  a  radiogram  could  be  made 
3howing  the  presence  of  two  foetuses,  it  would  be  useless  for  the 
diagnosis  of  the  presence  or  absence  of  union  of  the  twins,  unless, 
indeed,  the  union  were  an  osseous  one. 


VAEIETIES  OF  DOUBLE  MONSTEES. 

There  are  two  great  groups  of  united  twins :  in  the  first,  the  two 
foetuses  are  of  almost  equal  size,  and  are  symmetrically  disposed  and 
united  by  corresponding  parts  (e.g.,  chest  to  chest,  head  to  head, 
gluteal  regions  to  gluteal  regions);  in  the  second,  the  two  foetuses  are 
i of  different  sizes  (often  of  markedly  different  sizes),  are  asymmetri- 
cally disposed,  and  are  apparently  united  by  unlike  parts  (e.g.,  head 
;to  chest).  In  the  former  group  the  united  twins  may  be  called 
symmetrical  disomata,  and  in  the  latter  asymmetrical  disomata.  In 
i  the  former  group  each  twin  has  the  same  degree  of  formation  and 
vitality,  while  in  the  latter  one  of  them  is  obviously  a  parasite  upon 
the  other. 

It  is  not  with  the  parasitic  or  asymmetrical  disomata  that  the 
obstetrician  has  much  to  do.  Labour  may  indeed  be  retarded,  but 
;fche  degree  of  retardation,  the  means  which  require  to  be  taken  to 
iovercome  it,  and  the  effects  produced  upon  the  mother,  do  not  differ 


124  OPEEATIVE  MIDWIFERY 

from  those  met  with  in  cases  of  localized  enlargement  of  the  fa'tus 
from  any  cause  whatever  (e.g.,  fu-tal  ascites,  hydrocephalus,  etc.). 
For  instance,  in  a  case  of  foetus  in  foetu  (included  fdtus)  reported  by 
Wright  and  Wylie1  the  labour  was  long  and  difficult  on  account  of 
the  large  size  of  the  infant's  abdomen.  Some  time  after  her  birth  the 
infant  was  operated  upon,  and  a  mass  removed  from  the  cavity  of  the 
lesser  peritoneum.  This  mass  was  sent  to  me  for  examination,  and  I 
reported  that  it  was  an  included  twin  fcetus  of  the  variety  known  as 
amorphus  or  anideus,  and  that  by  increasing  the  size  of  the  abdomen 
of  the  co-twin  it  had  led  to  the  delay  and  difficulty  in  labour. 
Instances  might  be  multiplied,  but  I  pass  to  the  consideration  of  the 
obstetrical  relations  of  the  symmetrical  disomata  or  united  twins  in 
the  ordinary  sense  of  the  term. 

There  are  three  great  subdivisions  of  the  symmetrical  disomata. 
For  convenience  and  ease  of  description  these  groups  may  be  called 
the  chioid,  the  hypsiloid,  and  the  lambdoid  united  twins,  the  names 
being  given  to  them  on  account  of  their  resemblance  to  the  Greek 
letters  Chi,  Upsilon,  and  Lambda  respectively.  In  other  words,  the 
united  foetuses  in  these  three  subdivisions  have  the  shape  of  an  X,  of 
a  Y,  and  of  a  small  Lambda  or  an  inverted  Y  respectively.  In  text- 
books of  teratology  and  antenatal  pathology  they  are  more  often 
called  thoracopagous,  dicephalous,  and  syncephalous  fused  or  united 
twins;  but  from  the  present  obstetric  standpoint  I  think  it  will  be 
helpful  to  keep  the  general  construction  of  the  monstrosities  before 
the  mind's  eye  by  means  of  these  short  descriptive  names — X-shaped, 
Y-shaped,  and  inverted  Y-shaped.  The  first  group  contains  the  cases 
in  which  there  are  two  almost  perfectly  formed  infants  united  more  or 
less  completely,  thorax  to  thorax  or  back  to  back ;  the  second  contains 
the  two-headed  monstrosities,  in  which  the  lower  parts  are  more  or 
less  fused  into  one ;  and  the  third  includes  the  single-headed  mon- 
strosities, which  show  duplication  of  the  lower  limbs  and  sometimes 
of  the  lower  part  of  the  trunk  as  well. 

LABOUR  IN  THE  CASE  OF  THE  CHIOID  DOUBLE  MONSTERS. 

When  one  looks  at  chioid  united  twins  (Fig.  (5!)),  whether  of  the 
kind  in  which  the  place  of  union  is  situated  anteriorly  (region  of 
thoraces  or  of  abdomens),  or  of  that  in  which  the  twins  are  fused  in 
the  gluteal  regions,  the  first  thought  which  comes  into  one's  mind  is 
that  it  must  be  impossible  for  such  twins  to  pass  alive  and  uninjured 
through  the  genital  canal.  Yet,  as  a  matter  of  fact,  records  of  the 
live  birth  of  such  monsters  are  found  in  obstetric  literature,  both  old 
1  Brit.  Med,  Jowrn.,  vol.  ii.,  1900,  p.  142*. 


VARIETIES  OF  DOUBLE  MONSTERS  125 

;ind  recent.  It  is  true  that  the  confinement  is  occasionally  stated  to  have 
been  premature,  and  that  the  twins  themselves  are  generally  smaller 
than  single  foetuses  of  the  same  age,  yet  cases  are  not  wanting  in 


Fig.  69.— Chioid  or  Thoracopagous  Monster.     (Haultain.) 

which  they  have  been  of  good  size  and  born  at  full  term.  There  is, 
of  course,  the  well-known  instance  of  the  Siamese  twins,  and  of  late 
years  Chapot-Prevost  has  recorded  the  case  of  Chinese  brothers  born 


L26  OPERATIVE   MIDWIFKIlY 

alive,  and  surviving  birth,  at  the  full  term.     In  the  latter  example  it  is 
further  affirmed  that  the  mother  of  the  united  twins  was  a  priniipara.1 

From  a  scrutiny  of  the  cases  in  which  details  of  the  confinement 
are  given  (not  a  very  large  number,  it  may  be  remarked)  it  would 
seem  that  the  natural  mechanism  of  delivery  (if  it  may  be  so  called) 
has  been  as  follows  :  The  united  twins  have  presented  by  the  feet,  the 
bodies  have  descended  parallel  to  each  other  through  the  vaginal 
canal,  and  then  the  obstetrician  has  carried  the  bodies  well  forward 
over  the  symphysis  pubis,  with  the  result  that  the  posterior  head  has 
engaged  in  the  pelvis  and  been  born,  while  the  anterior  head  has  then 
been  able  to  follow.  This  seems  to  have  been  the  mechanism  which 
proved  effectual  in  the  case  recorded  by  ]  )r.  Haultain  in  the  Transac- 
tions of  the  Edinburgh  Obstetrical  Society  for  1901-1902.2  When 
the  obstetrician  has  been  successful  in  the  management  of  one  of  1 
these  labours,  it  will  generally  be  found  that  he  has  imitated  as  far  as- 1 
possible  the  natural  mechanism  indicated  above.  Version,  therefore, ' 
gives  the  best  results  as  a  rule,  for  by  its  means  the  feet  are  made  to 
present  and  the  natural  mechanism  facilitated.  The  chief  difficulty 
will  arise  in  connexion  with  the  birth  of  the  heads.  Here,  a^ain,  the 
rule  is  to  imitate  Nature,  and  get  the  posterior  head  to  enter  the  pelvis, 
first,  the  bodies  for  this  purpose  being  carried  well  forward  over  the 
symphysis  pubis. 

Occasionally  cases  have  been  recorded  in  which  delivery  has  taken 
place  or  been  brought  about  without  performing  version,  and  in  which, 
nevertheless,  the  heads  have  been  the  presenting  parts.  Such  cases 
almost  necessarily  imply  that  the  maternal  pelvis  has  been  large.  In 
H.  Hanks'  case3  the  double  foetuses  presented  by  the  heads.  One 
head  was  born  first,  the  other  in  the  meantime  occupying  the  space 
between  the  chin  of  the  first  twin  and  its  chest ;  then  the  second  head 
was  expelled  with  the  help  of  traction  on  the  first ;  and  then  the  two 
bodies  came  away  simultaneously.  But  the  two  heads  do  not  always 
come  away  together,  as  they  did  in  Hanks'  case.  In  an  interesting 
record  by  P.  Boulton4  the  following  details  are  given.  The  mother 
was  a  small,  weak  woman,  thirty-seven  years  of  age,  who  had  had 
eight  pregnancies,  all  ending  in  normal  confinements.  In  the  present 
labour  the  first  head  presented  as  a  face;  forceps  was  applied  and 
the  first  head  extracted.  Next,  the  shoulders,  arms,  and  trunk  of  this 
child  were  brought  down  ;  then  the  four  feet  and  the  trunk  ;  and 
finally  the  head  of  the  second  twin  appeared  at  the  vulva,  and  was 
born  in  that  order.     The  labour  was  premature  and  the  fused  twins 

1  •  Chirurgie  cles  Teratopages,'  Chapot-Pn'vost ;  Paris,  1901. 

-  Trims.  Edirj.  Obst.  Soc,  vol.  xxvii.,  p.  176. 

:;  Trans.  Obst.  Soc.  Lond.,  1862,  vol.  iii.,  p.  414.     4  Ibid.,  1882,  vol.  xxiii..  p.  260. 


CHIOID  OK  THORACOPAGOUS  MONSTERS  127 

iixiall ;   but  for  these  facts   it  is  doubtful  whether   such   a   mode  of 
lelivery  could  have  taken  place. 

When  a  part  of  the  fused  twins  has  been  expelled,  and  when  no 
iirther  progress  takes  place,  or  can  be  accomplished  by  ordinary 
)bstetric  measures,  the  indication  will  be  to  reduce  the  size  of  the 
>roduct  of  conception  by  embryulcia;  but  it  will  be  advisable  to 
•egulate  the  plans  of  procedure  as  far  as  possible.  If,  for  instance, 
he  connecting  band  between  the  foetuses  can  be  reached,  and  if  it 
)e  not  of  too  solid  a  nature,  the  obstetrician  will  divide  it,  and  then 
leliver  the  foetuses  separately.  If  one  head  be  at  the  vulva  and  the 
>ther  be  jammed  in  the  pelvis,  decapitation  of  the  first  head  may 
nake  it  possible  to  complete  the  delivery.  In  almost  any  of  the 
mpacted  cases  the  performance  of  cleidotonry  (division  of  one  or  both 
lavicles)  will  facilitate  other  obstetric  manoeuvres,  if  it  does  not  of 
tself  make  labour  possible.  Craniotomy  of  one  or  both  heads  may 
>e  necessary ;  and  in  a  case  in  which  the  specimen  afterwards  came 
n to  my  possession  for  examination  both  heads  as  well  as  the  two 
ibdomens  had  been  opened  into  before  the  foetuses  could  be  extracted. 
n  all  such  cases  the  obstetrician  will,  of  course,  do  his  best  to  prevent 
:epsis,  and  will  be  well  advised  to  wash  out  the  interior  of  the  uterus 
horoughly.  One  of  the  great  dangers  associated  with  the  delivery  of 
louble  monsters  of  this  type  is  the  fact  that  not  infrequently  several 
nedical  men  have  to  do  with  the  case,  either  as  principal  or  con- 
stant or  assistant,  and  that  several  different  hands  may  thus  be 
>assed  into  the  uterus  during  the  manipulations,  each  hand,  of 
:ourse,  increasing  the  risk  of  sepsis.  Further,  the  labour  is  often  a 
>rolonged,  an  anxious,  and  a  disappointing  one  (dead-born  infant), 
i,nd  for  these  reasons  the  patient  may  be  less  able  to  resist  septic 
nfection. 


LABOUR  IN  THE  CASE  OF  HYPSILOID  DOUBLE  MONSTERS. 

The  dicephalous  or  hypsiloid  fused  twins  (Fig.  70)  have  two  heads, 
hree  or  four  upper  limbs,  two  necks,  a  body  showing  some  signs  of 
luplicity,  and  (usually)  only  two  legs,  which  belong  one  to  each  head. 
^.  classic  case  of  this  type  of  double  monster  is  the  S sottish  brothers 
vho  lived  during  the  reigns  of  James  III.  and  James  IV.,  and 
attained  to  the  age  of  twenty-eight  years  ;  another  instance  is  that 
>f  Ritta-Christina,  born  in  Sardinia  in  1829,  and  living  for  a  few 
nonths ;  and  yet  another  is  that  of  the  Tocci  brothers,  born  in 
taly  in  1877.  It  is,  however,  somewhat  uncommon  for  fusei  twins 
>f  this  type  to  survive  birth,  although,  as  a  matter  of  fact,  the 
-bstetrical  conditions  are  not  worse,  but  better,  than  those  of  the 


128 


OPERATIVE  MIDWIFERY 


chioid  type.  In  Dr.  Pallaros'  case  of  dicephalue  which  I  reported 
some  time  ago1  the  cause  of  the  futal  death  seems  to  have  been  the 
complication  of  the  labour  with  a  placenta  pnevia. 

The  obstetrical  history  of  the  hypsiloid  twins  closely  resembles  in 
its  main   outlines  that  of  the  chioid  type.     If  the  presentation  be 


*'„;.  70.— Hypsiloid  or  Dicej'halous  Monster.     (Ihmteriaii  Museum,  Glasgow  University.) 

breech  or  footling,  the  single  body  is  born  with  perhaps  some  delay; 
then  the  first  head  enters  the  pelvis,  and,  if  it  be  the  posterior  one  of 
the  two,  is  expelled  by  pulling  the  body  well  forward ;  then  the  second 
or  anterior  head  follows  without  further  difficulty.  It  may,  however, 
be  necessary  to  decapitate.  A  fairly  typical  case  is  thus  described  by 
1  •  Teratologia,'  1895,  ii.  210. 


LAMBDOID  OB  SYNCEPHALOUS  MONSTERS    129 

Horrocks : x  '  The  presentation  was  breech,  and  nothing  abnormal 
was  found  until  the  child  was  born  as  far  as  the  shoulders.  Two 
necks  and  two  chins  were  now  made  out.  The  left  head  was  anterior 
and  lower  than  the  right,  both  faces  looking  towards  the  mother's 
right.  The  pains  were  strong,  and  presently  the  right  head  descended 
below  the  sacral  promontory,  got  lower  than  the  left  head,  swept  over 
the  perineum,  and  was  born  first,  with  the  occiput  posterior  and  to  the 
left.  The  left  head  was  born  last.'  In  a  case  reported  by  Phillips2 
the  anterior  head  was  born  first,  but  the  labour  was  premature. 

When  the  heads  present,  delivery,  if  it  can  occur  at  all,  takes  place 
in  the  following  way  :  One  head  is  born  and  becomes  fixed  under 
the  arch  of  the  pubes ;  then  the  body  is  driven  past  it  by  a  sort  of 
spontaneous  evolution ;  and  finally  the  second  head  emerges.  If,  as 
is  not  uncommon,  the  delivery  cannot  be  effected  by  this  mechanism, 
it  will  be  necessary  to  decapitate  the  first  head  and  perform  version. 
The  same  precautions  must  be  taken,  as  regards  asepsis  and  the 
avoidance  of  prolonged  and  purposeless  traction,  with  the  hypsiloid 
as  with  the  chioid  fused  twins.3 


LABOUR  IN  THE  CASE  OF  LAMBDOID  DOUBLE  MONSTERS. 

The  cases  are  comparatively  rare  in  which  the  fcetuses  are  fused 
in  the  region  of  the  heads  (Fig.  71)  and  upper  part  of  the  trunks,  and 
separate  in  the  lower  parts  and  the  lower  limbs.  The  name  lambdoid 
twins  may  be  given  to  such  monsters,  although  the  more  familiar 
ippellation  is  syncephalic  (fused  heads).  The  obstetrical  difficulties 
ire  in  these  cases  usually  associated  with  the  large  size  of  the  single 
bead,  for,  although  single,  it  represents  two  heads,  indications  of 
which  are  often  forthcoming  in  the  presence  of  two  faces.  The  name 
Janus  foetus '  has  been  given  to  it  on  account  of  the  existence  of  the 
;wo  faces,  which  are  sometimes  placed  side  by  side  (with  a  common 
ientral  eye)  or  back  to  back.  If  in  such  cases  the  lower  extremities 
present  first,  it  is  quite  likely  that  the  two  bodies  may  be  born,  with 
some  delay,  perhaps,  but  without  any  great  difficulty ;  but  the  after- 
ioming  head  will  remain  at  the  brim  of  the  pelvis.  The  necessity 
vill  then  arise  for  perforation,  and  perhaps  for  basilysis,  of  that  head, 
;md  in  order  to  reach  it  easily  it  may  be  good  practice  to  reduce  the 
mlk  of  the  shoulders  by  cleidotomy.     If,  on  the  other  hand,  the  head 

1  Trans.  Obst.  Soc  Lond.,  1885,  vol.  xxvL,  p.  326. 

2  Ibid.,  1887,  vol.  xxviii.,  p.  278. 

3  Interesting  details  (with  a  bibliography)  of  the  birth  of  dicephalic  double 
aonsters  are  given  by  Dr.  J.  Phillips  (Edin.  Med.  Journ.,  1888,  vol.  xxxiii.,  pp.  308. 
04). 

9 


L80 


OPERATIVE  MIDWIFERY 


presents,  the  case  will  no  doubt  be  treated  by  the  usual  methods,  for 
the  obstetrician  will  not  guess  that  there  are  two  bodies  following  ;  in 


Fig.  71.— Lambdoid  or  Syncephaloua  Monster.     (Hunterian  Museum,  Glasgow  Univerei™ 

other  words,  forceps  will  be  applied,  and  will  doubtless  fail,  and  then 
recourse  will  be  had  to  perforation.  Probably  it  will  be  necessary  to 
reinforce  the  perforation  by  considerable  comminution  of  the  head 


LAMBDOID  OR  SYNCEPHALOUS  MONSTERS  131 

(removal  of  large  pieces  of  the  cranial  vault  bones)  and  by  basilysis. 
Since,  however,  these  lambdoid  double  monsters  have  usually  a  very 
repulsive  appearance,  and  little  chance  of  surviving,  there  need  be 
little  hesitation  in  pursuing  the  line  of  treatment  indicated  above. 

There  are  some  types  of  double  monster  which  do  not  fall  into  any 
one  of  the  three  groups  referred  to  ;  but,  as  a  rule,  the  obstetric  diffi- 
culties they  cause  are  no  more  than  those  which  would  be  produced 
by  separate  twins.  Thus,  in  the  very  rare  cases  of  crcmiopagus  (in 
which  the  two  fee tuses  are  united  by  the  vertices  of  the  crania,  and  are 
separate  in  all  the  other  regions)  one  twin  is  born  by  the  feet,  the  two 
heads  come  one  after  the  other,  and  finally  the  body  and  limbs  of  the 
second  twin  appear.  The  craniopagous  fused  twins  may  survive  birth 
for  months,  even  for  years. 


. 


CHAPTKlf  X 

DYSTOCIA  THE  RESULT  OF  ABNORMALITIES  AFFECTING  THE 

FCETUS — Continued 

Cord^Placenta— Membranes. 

COMPLICATIONS  CONNECTED  WITH  THE  CORD. 

Presentation  and  Prolapse  of  the  Funis  or  Cord. — In  considering 
this  subject,  it  is  still  the  custom  of  many  to  follow  the  classification 
of  Naegele,  and  distinguish  between  'presentation  and  prolapse  of  the 
funis,  the  former  being  a  falling  down  of  the  cord  in  front  of  the 
presenting  part  before  rupture  of  the  membranes,  and  the  latter  being 
a  similar  occurrence  after  rupture.  The  distinction  is  useful,  as  the 
treatment  for  the  two  conditions  is  quite  different.  Doubtless,  prolapse 
in  most  cases  is  a  natural  consequence  of  presentation,  but  in  not  a 
few  it  is  only  with  rupture  of  the  membranes  and  the  escape  of  the 
liquor  amnii  that  the  former  occurs,  while  occasionally  the  latter 
has  disappeared  during  the  course  of  labour.  The  frequency  of  the 
condition  in  the  Glasgow  Maternity  Hospital  is  1  in  150  cases. 

Speaking  generally,  the  conditions  favouring  the  occurrence  of 
prolapse  of  the  funis  are  those  which  interfere  with  the  close  applica- 
tion of  the  presenting  part  to  the  lower  segment  of  the  uterus.  The 
head  of  the  foetus  best  accommodates  itself  to  the  lower  pole  of  the 
uterus ;  consequently,  prolapse  of  the  cord  is  much  less  frequent  with 
it  than  with  pelvic  and  transverse  presentations.  Von  Winckel1  found 
transverse  presentations  twenty  to  twenty-five  times  and  breech  nine 
to  ten  times  as  often  as  head  presentations.  For  the  Glasgow  Mater- 
nity Hospital  the  figures  are  :  Head,  73  per  cent. ;  breech,  6  per  cent.; 
transverse,  21  per  cent. 

Malformations  of  the  pelvis,  and  tumours  of  the  uterus  and  sur- 
rounding parts,  by  hindering  the  engagement  of  the  presenting  part, 
also  favour  prolapse,  while  such  conditions  as  low  implantation  of 
the  placenta,  marginal  attachment  of  the  cord,  undue  length  of  cord, 
sudden  rupture  of  the  membranes,  especially  if  the  parturient  is  in  an 

1  '  Handbuch  der  Geburtshiilfe,'  Bd.  ii.,  Teil  iii.,  1905,  p.  1522. 

132 


COMPLICATIONS  CONNECTED  WITH  THE  CORD       183 

tt'ect  position,  need  only  be  mentioned.     They  are  evident  and  impor- 
tant factors. 

The  condition  is  found  about  five  times  as  often  in  multipara?  as 
n  primiparse.     But  it  is  at  once  apparent  that  such  a  comparison  does 


Fio.  72. — Prolapse  of  Cord.     (Bumm.) 

not  really  give  a  correct  idea  of  the  relative  frequency  in  primiparse, 
the  practical  bearing  of  which  is  that  it  is  more  common  in  the  latter 
than  is  generally  supposed. 


134  OPERATIYK  MIDWIFERY 

The  position  of  the  prolapsed  funis  depends  chiefly  upon  the 
position  of  the  foetus,  for  the  cord  tends  to  fall  down  on  the  side  to 
which  its  abdomen  is  directed.  It  is,  consequently,  usually  found  to 
one  or  other  side  of  the  promontory  (Fig.  72),  rarely  in  front  or  at  the 
sides  of  the  pelvis.  If  it  does  prolapse  in  front,  as  in  occipito-posterior 
positions,  it  will  usually  be  found  in  the  neighbourhood  of  the  right 
ileo-pectineal  eminence. 

The  extent  to  which  the  cord  prolapses  varies.  Sometimes  only 
a  small  loop,  but  at  other  times  many  inches,  fall  down.  Be  the  loop, 
which  is  compressed,  large  or  small,  the  danger  to  the  child  is  grave 
if  the  condition  is  left  alone.  A  small  loop  is  more  easily  replaced  and 
kept  up  ;  it  is  more  readily  overlooked,  however. 

Few  conditions  simulate  a  prolapsed  cord.  None  if  pulsations  in 
it  can  be  felt.  Sometimes,  when  there  is  great  difficulty  in  reaching 
the  presenting  part,  the  tips  of  the  child's  toes  or  fingers  resemble  it, 
for  they  move  away  from  the  examining  finger  just  as  the  cord  does. 
It  is  commonly  stated  that  the  prolapsed  intestines  of  the  mother  or 
child  may  be  confused  with  it  also  ;  and  certainly  in  cases  of  ruptured 
uterus  I  have  felt  the  prolapsed  intestine  very  much  like  the  funis,  but 
only  for  a  moment  was  there  any  doubt  as  to  the  real  nature  of  the 
condition. 

Until  recently  I  thought  nothing  could  really  simulate  a  prolapsed 
cord,  but  I  was  disabused  of  the  idea,  for  in  a  patient  I  was  attending, 
and  in  whom  it  was  extremely  difficult  to  reach  the  presenting  part, 
owing  to  her  stoutness,  a  flattened,  pedunculated,  submucous  myoma 
exactly  resembled  the  cord  (Fig.  73).  Indeed,  I  only  came  to  a 
diagnosis  after  putting  the  patient  under  chloroform  and  inserting  my 
hand  into  the  vagina. 

From  what  has  been  said,  it  is  evident  that  prolapse  of  the 
cord  can  only  be  diagnosed  by  vaginal  examination,  and,  conse- 
quently, a  labour  must  not  be  conducted  by  abdominal  palpation 
alone,  as  some  enthusiasts  of  abdominal  palpation  advocate.  I  am 
perfectly  well  aware  that  interference  with  the  circulation  of  the 
cord,  such  as  results  from  pressure  upon  it  when  prolapsed,  produces 
alterations  in  the  fatal  pulse-rate  and  rhythm  which  can  be  recog- 
nized by  auscultation.  But  the  important  point  is,  that  by  the  time 
the  alterations  are  distinct  the  child  may  have  suffered  considerable 
injury. 

Having  ascertained  that  the  prolapsed  body  is  the  cord,  one  must 
estimate  the  presence  and  strength  of  the  pulsations.  This  can  be 
done  by  pressing  the  cord  against  the  fcctal  head  or  maternal  pelvis, 
or,  better  still,  feeling  it  between  the  two  examining  fingers.  The 
sources  of  error  are  the  pulsations  in  the  mother's  vessels  and  in  the 


COMPLICATIONS  CONNECTED  WITH  THE  COED       135 


Fig.  73.— Flattened  Submucous  Myoma  which  simulated  a  Prolapsed  Cord. 
(Author's  Case.) 

examining  fingers  of  the  accoucheur,  and  I  must  admit,  if  the  foetal 
pulsations  are  feeble  and  slow,  it  is  sometimes  not  a  little  difficult  to 
exclude  these  fallacies,  unless  one  has  the  cord  actually  between  one's 
ringers. 


136  OPEBATIVE  MIDWIFERY 

The  child,  it  must  be  remembered,  is  not  always  dead,  even 
although  pulsations  in  its  cord  are  absent.  "When  the  cord  is  com- 
pletely compressed — during  a  uterine  contraction,  for  example — the 
pulsations  cease  entirely,  although  they  return  again  as  the  contrac- 
tion passes  off.  Again,  as  the  child  dies  slowly,  it  is  evident  that  the 
heart  will  continue  beating  some  time  after  the  pulsations  cease  to  be 
appreciated.  Everyone  has  had  experience  of  the  former  condition, 
and  I  have  once  or  twice  had  experience  of  the  latter,  but  I  have  no 
recollection  of  ever  having  saved  a  child  under  the  latter  circum- 
stances. "When  the  pulsations  are  slow,  and  especially  if  they  are 
feeble  and  irregular,  one  must  extract  the  child  quickly  if  it  is  to 
be  saved. 

Prognosis. — In  prolapse  of  the  cord  one  has  obviously  to  deal 
with  a  complication  in  which  the  chief  danger  is  to  the  child.  The 
mechanical  obstruction  of  the  cord  to  delivery  is  quite  negligible, 
so  that  the  mother  can  only  be  injuriously  affected  by  the  operative 
interference  that  may  be  had  recourse  to  in  the  interests  of  the 
child. 

The  foetal  mortality  is  very  high,  but  owing  to  the  fact  that  the 
conditions  which  favour  prolapse  prevent  engagement  of  the  head, 
the  cord  often  escapes  pressure.  It  is  more  likely  to  be  unfavourably 
pressed  on  when  the  presentation  is  a  head  and  the  pelvis  is  normal. 
Up  to  a  certain  point  in  the  labour  the  condition  is  most  favourable 
with  transverse  presentations,  so  much  so  that  a  temporary  conver- 
sion into  a  transverse  presentation  while  the  os  is  dilating  has  been 
suggested.  With  a  contracted  pelvis,  also,  I  have  frequently  seen 
the  prolapsed  cord  but  little  pressed  upon.  In  one  of  my  cases  of 
Cesarean  section  the  cord  was  down  in  the  vagina  for  an  hour  and 
a  half  after  rupture  of  the  membranes,  and  yet  it  continued  pulsating 
quite  normally.     The  child  was  extracted  alive. 

As  a  rule,  in  a  particular  case  the  presence  or  absence  of  the 
intact  membranes  is  the  most  important  circumstance  influencing  the 
prognosis.  Speaking  generally,  presentation  of  the  cord — that  is, 
falling  down  of  the  cord  when  the  membranes  are  intact — is  of  little 
immediate  consequence.  It  simply  indicates  that  when  the  mem- 
branes rupture  it  will  be  endangered.  Still,  this  is  not  always  the 
case,  for  if  there  is  little  '  fore-water,' and  the  head  is  low  in  the 
pelvis,  there  will  certainly  be  undue  pressure  on  the  cord,  even 
although  the  membranes  are  intact.  Next  in  importance  is  the 
degree  of  dilatation  of  the  cervix,  as  it  is  self-evident  that  delivery  or 
replacement  are  difficult  in  proportion  to  the  expansion  of  the  cervix. 
Then,  again,  the  extent  of  the  prolapse  distinctly  influences  the  prog- 
nosis, for  the  more  cord  down,  the  more  difficult  it  is  to  get  it  replaced 


COMPLICATIONS  CONNECTED  WITH  THE  CORD      137 

,nd  retained  in  a  safe  situation.  Lastly,  any  coexisting  complica- 
ions  affect  the  outlook  unfavourably. 

Treatment. — The  treatment  to  be  adopted  in  the  complication 
inder  consideration  depends  upon  several  circumstances.  Chief  of 
hese  are,  the  condition  of  the  membranes,  the  condition  of  the  child, 
,nd  the  extent  to  which  the  parturient  canal  is  dilated. 

When  the  membranes  are  unruptured  and  the  os  only  partially 
lilated,  all  one's  energies  must  be  directed  to  preserving  the  mem- 
•ranes  intact,  for  except  in  those  comparatively  rare  cases  where  the 
•resenting  part  is  low  in  the  pelvis,  with  little  fore-water,  the  cord  is 
afe  from  pressure.  With  that  object  in  view,  the  patient  is  kept  in 
ied,  and  all  vaginal  examinations  and  manipulations  are  desisted 
rom.  In  addition,  an  attempt  is  made  to  replace  the  cord  by  change 
f  posture.  The  positions  which  are  employed  are  the  genu-pectoral 
r  knee-elbow  position,  Sims',  and  Trendelenburg's.  All  act  in  the 
ame  way.  They  raise  the  pelvis,  and  bring  the  cervix  to  a  higher 
3vel  than  the  fundus,  and  so  permit  gravity  to  act  on  the  prolapsed 
Dop.  It  is  stated  that  ballotting  the  fundus  with  the  hand  favours 
he  return  of  the  cord.  Theoretically,  the  treatment  is  sound,  but, 
.nfortunately,  it  does  not  always  prove  successful  in  practice. 

Sims'  position  (Fig.  74)  is  quite  as  good  as,  and  less  irksome  than, 
he  knee-elbow  or  the  Trendelenburg  position.  It  also  possesses  this 
dvantage,  that  it  lessens  the  risk  of  premature  rupture  of  the  mem- 
ran  es.  As  a  further  preventative  to  this  occurring,  the  employment 
f  a  hydrostatic  dilator,  introduced  into  the  vagina,  is  recommended, 
'ersonally,  I  have  never  employed  the  metreurynter  at  this  stage  and 
ith  the  object  mentioned. 

The  course  to  pursue,  in  cases  of  prolapse  of  the  cord  with 
uptured  membranes,  will  depend  upon  the  condition  of  the  child 
nd  the  degree  of  dilatation  of  the  cervix.  It  is  perfectly  evident  that 
the  pulsations  in  the  cord  have  ceased,  and  the  child  is  dead, 
othing  need  be  done  in  its  interest,  and  so  the  labour  should  be 
llowed  to  pursue  its  ordinary  course.  Any  interference  must  be  in 
ae  direction  of  making  the  delivery  as  easy  as  possible  for  the 
lother.  For  example,  in  such  a  condition,  if  uterine  contractions 
ail,  and  the  extraction  of  the  child  is  deemed  necessary,  the  fore- 
oming  head,  delivered  by  forceps,  or  the  after-coming  head,  delivered 
y  traction  on  the  trunk,  may  be  perforated,  so  as  to  remove  all 
hance  of  the  head  doing  damage  to  the  soft  parts  of  the  parturient 
anal.  I  have  several  times  perforated  the  head  already  grasped  by 
le  forceps,  and  have  always  been  satisfied  that  it  lessened  the  bulk 
I  the  head,  and  did  not  render  the  instrument  appreciably  more 
able  to  slip. 


IMS 


ol'KKATIYK    MlD\Yin:i;Y 


One  must,  however,  be  quite  sure  that  the  pulsations  have  ceased, 
and  so  the  loop  of  prolapsed  cord  must  he  carefully  felt,  not  only 
during  the  '  pains,'  but  also  in  the  intervals  between  them.  As  I 
have  pointed  out  elsewhere,  the  child  usually  dies  slowly,  and  for 
a  considerable  time  before  its  death  pulsations  may  be  quite  good 
during  the  intervals,  although  they  are  entirely  absent  while  the  pains 
are  in  progress.  One  should  also  observe  the  condition  of  the  fa-tal 
heart. 

If  the  os  is  fully  dilated,  the  child  should  be  extracted  by  forceps. 
In  cases  where  the  os  is  fairly  dilated  and  the  cord  has  been  pressed 


Fit;.  74. — Sims'  Position.     The  woman  lies  on  left  side,  with  right  leg  drawn  up  over  It  ft. 


upon,  it  may  be  not  a  little  difficult  to  decide  how  far  one  is  justified 
in  forcibly  delivering  the  child,  with  the  object  of  saving  it,  knowing, 
as  one  does,  that  by  such  a  course  one  appreciably  endangers  the 
mother.  From  my  experience,  I  would  say  that  when  the  foetal 
pulsations  slowly  return  in  the  intervals  between  the  uterine  contrac- 
tions, and  remain  slow  and  intermittent  and  irregular,  unless  the 
child  can  be  slipped  out  of  the  vagina  immediately  and  with  ease,  it 
is  profitless  to  add  to  the  maternal  risks  by  doing  anything  in  the 
interests  of  the  child.  When,  however,  regular  and  strong  pulsations 
return  immediately  after  the  uterine  contractions  have  passed  off,  and 


COMPLICATIONS  CONNECTED  WITH  THE  CORD      139 

ie  is  not  pressed  for  time,  manual  dilatation  or  incision  of  the  cervix 
ay  be  practised.  One  thing  must  never  be  done — viz.,  dragging  the 
lild  through  the  undilated  cervix  ;  for  with  the  after-coming  head  it 
absolutely  profitless,  as  the  child  will  certainly  perish,  owing  to  the 
faculty  and  delay  in  bringing  down  the  arms  and  head,  and  with 
le  fore-coming  head  it  causes  severe  and  irregular  laceration  of  the 
irvix  uteri.  But  in  such  cases  hard-and-fast  rules  cannot  be  laid 
3\vn.  Experience,  and  a  careful  consideration  of  all  the  circum- 
ances,  must  be  one's  guide. 

We  must  now  turn  to  prolapse  of  the  cord  when  it  is  recognized 
irlier,  and  when  there  is  still  a  possibility  of  replacing  it,  altering 
ie  posture  of  the  child,  or  introducing  a  hydrostatic  dilator.  As 
ated  already,  Louise  Bourgeois  (1609)  suggested  replacing  the  pro- 
psed  cord.  According  to  Fasbender,  our  latest  obstetric  historian,1 
ie  recommended  reposition  and  the  maintaining  of  the  cord  in  place 
v  means  of  a  tampon.  Guillemeau  and,  later,  Mauriceau  also  advo- 
ited  reposition,  although  the  latter  fully  appreciated  the  fact  that  it 
[ten  proved  unsuccessful.     De  la  Motte  opposed  reposition. 

As  forceps  became  perfected  and  more  generally  employed,  and 
fraction  by  means  of  it  was  recommended  by  Levret,  Smellie,  and 
.hers,  version  and  forceps  came  to  be  the  only  methods  of  treatment 
nployed.  Writing  in  1853,  Eigby  says  : 2  '  Reposition  has,  neverthe- 
ss,  met  with  so  little  success  as  to  have  fallen  into  complete  disuse 
ntil  the  last  few  years.'  A  revival  of  the  treatment  of  reposition  was 
utiated  by  Michaelis.  This  great  obstetrician,  best  known,  of  course > 
i  connexion  with  his  work  upon  deformities  of  the  pelvis,  wrote 
^veral  papers  upon  the  subject  of  prolapse  of  the  cord.  Basing  his 
pinions  on  his  own  results  (22  per  cent,  foetal  mortality),  he  became 
strong  advocate  of  the  treatment  by  reposition.  The  chief  value  of 
Lichaelis'  work  in  connexion  with  reposition  was  the  importance  he 
ttached,  and  that  very  rightly,  to  pushing  the  cord  above  the  retrac- 
on  ring.  About  this  time  a  great  variety  of  repositors  were  devised 
y  Braun,  Martin,  Murphy,  and  others. 

The  results  from  manual  reposition  for  the  last  five  years  in  the 
lasgow  Maternity  Hospital  show  a  fcetal  mortality  of  24  per  cent., 
nd  failure  to  effect  reposition  in  10  per  cent.  Beuter;!  has  made 
most  careful  analysis  of  some  1,600  cases,  and  his  figures  go  to 
apport  the  contention  that  the  best  results  are  now  obtained  by 
^position. 

Regarding  manual  reposition,  it  must  be  remembered  that  the 

1  Geschichte  der  Geburtshiilfe,  1906,  p.  157. 

2  '  A  System  of  Midwifery,'  p.  236. 

3  Inaug.  Dis.,  Bonn,  1894. 


140 


( >ll :  l:\ll  \  i:  MIDWIFERY 


results  obtained  before  the  clays  of  anesthesia,  when  the  cord  was  not 
pushed  up  high  enough,  cannot  be  compared  with  those  of  to-day. 


Fig.  75. —  Simple  Devices  for  replacing  the  Cord.     (After  Edgar.) 

I  have  no  hesitation  in  recommending  replacement  of  the  cord  under 
anaesthesia.     When  the  os  is  sufficiently  dilated,  the  cord  may  be 


COMPLICATIONS  CONNECTED  WITH  THE  CORD       141 

replaced,  and  at  the  same  time  hooked  over  a  limb.  When,  however, 
the  os  is  not  sumciently  dilated  to  permit  of  manual  replacement, 
repositors  may  be  employed.  The  earliest  repositor  used  was  gauze , 
and  it  and  a  large  sponge  have  frequently  proved  of  value.  Of  the 
various  repositors,  the  most  effective  and  the  simplest  is  the  catheter, 
employed  as  seen  in  the  illustration  (Fig.  75).  A  loop  of  a  double 
thread  of  silk  ligature  or  thin  tape  is  brought  out  through  the  eye  of 
a  gum-elastic  catheter.  The  prolapsed  piece  of  cord  is  then  inserted 
into  the  loop  in  one  of  the  manners  shown.  The  catheter  and  cord 
are  then  carried  up  into  the  uterus,  and  the  silk  thread  loosened  by 
moving  the  catheter  about  or  removing  the  stilette. 

In  the  majority  of  our  cases  where  the  cord  was  replaced,  delivery 
was  completed  by  forceps.  With  the  latter  the  results  have  been 
infinitely  better  than  with  version,  which  gave  a  fcetal  mortality 
of  56  per  cent.  It  must  be  admitted,  however,  that  version  was 
performed  late,  and  in  many  of  the  cases  the  pelvis  was  decidedly 
deformed.  My  feeling  with  regard  to  the  operation  is  that,  if  it  is 
to  prove  successful,  one  would  require  to  perform  it  prior  to  rupture 
of  the  membranes,  or,  at  least,  immediately  rupture  occurred.  A& 
we  have  seen,  however,  everyone  is  agreed  that  it  is  the  greatest 
possible  mistake  to  rupture  the  membranes  prior  to  full  dilatation 
of  the  os  externum ;  and  consequently  I  think  version  is  unsuitable, 
except  in  tranverse  presentations,  or  some  coexisting  complication, 
such  as  placenta  prsevia. 

The  metreurynter  of  Champetier  de  Eibes,  or  similar  hydrostatic 
dilators,  are  favoured  by  only  a  few  enthusiasts,  for  the  cord  may 
be  compressed  between  the  rubber  bag  and  the  uterine  wall  just  as 
readily  as  between  the  foetal  head  and  the  uterine  wall. 

Before  leaving  the  subject,  let  me  say  that  in  certain  cases  of 
contracted  pelvis  I  have  seen  the  cord  so  little  pressed  upon,  even 
with  the  membranes  ruptured,  that  I  have  not  interfered.  I  simply 
examined  the  condition  of  the  cord  from  time  to  time,  and  auscultated 
the  foetal  heart  regularly.  In  such  cases  the  real  danger  to  the  child  is 
when  the  head  has  passed  the  brim  and  is  in  the  cavity.  Consequently, 
all  that  is  necessary  is  to  direct  the  cord  into  one  of  the  '  bays '  at  the 
side  of  the  promontory,  and  leave  the  case  to  Nature  until  the  os 
is  sumciently  dilated  and  the  head  is  moulded.  The  forceps  are 
then  applied,  or  any  other  operation  had  recourse  to  which  is  deemed 
suitable  for  the  particular  case. 

Shortness  of  the  Umbilical  Cord. — The  umbilical  cord  may  be 
actually  short,  or  relatively  short  by  reason  of  its  being  wound  round 
some  part  of  the  foetus — most  usually  the  neck.  Actual  shortness  of 
the  cord  causing  dystocia  is  very  rare.     I  have  only  witnessed  it  on 


112 


OPEEATIVE  MIDWIFERY, 


two  occasions:  once  in  the  malformed  fu.*tus  shown  in  the  illustration 
(Fig.  76),  and  once  in  an  otherwise  normal  fntus,  where  it  measured 


Fig.  7b'.— Adhesions  between  Amnion  and  Head;  also  Extreme  shortness  of  tin-  Cord  in 
a  Foetus  horn  Alive,  and  presenting  many  Recognizable  Malformations.  (Author's 
Collection.) 

about  8  inches  (20  centimetres).    In  the  latter  case,  during  the  extrac- 
tion of  the  trunk  (the  child  presented  by  the  vertex),  I  felt  that  the 


COMPLICATIONS  CONNECTED  WITH  THE  CORD      143 

child  was  prevented  from  escaping  owing  to  the  shortness  of  the  cord, 
and  so  divided  the  latter  and  completed  the  delivery.  Similar  cases 
have  been  recorded  by  many  others.  Among  the  most  interesting  was 
the  one  described  by  Braxton  Hicks,1  where  actual  shortness  of  both 
cords  in  a  twin  pregnancy  was  very  marked.  In  the  first  child,  which 
presented  by  the  breech,  the  funis  was  exceedingly  short,  so  that  it 
scarcely  could  be  tied  and  divided.  The  second  child,  dead  and 
(.edematous,  also  presented  by  the  breech.  As  the  latter  had  been 
long  delayed  at  the  outlet,  the  author  states :  '  I  hooked  a  crotchet 
into  its  abdomen ;  some  fluid  escaped,  which  allowed  more  freedom 
of  action.  I  now  could  feel  the  funis  very  tense,  the  umbilicus  being 
stretched  up.  It  was  above  the  symphysis  pubis.  I  determined  to 
divide  the  funis,  and  having  in  my  bag  the  osteotome  of  the  late 
Sir  James  Simpson,  I  guided  it  up  between  two  fingers  of  one  hand 
and  divided  it.  Upon  using  fair  traction,  the  body  came  down.  The 
funis  was  about  4  inches  (10  centimetres)  long  altogether.'  Bayer2 
describes  a  case  where  the  cord  measured  4*2  inches  (10*5  centi- 
metres). The  most  extreme  cases  of  shortness  are  found  in  associa- 
tion with  malformations,  more  particularly  exomphalos,  as  in  the 
preceding  illustration.  It  would  appear  that  shortness  below  10  inches 
(25  centimetres)  usually  gives  rise  to  more  or  less  dystocia. 

With  relative  shortening  of  the  cord,  the  latter  is  usually  found 
round  the  neck  of  the  child,  for  the  shoulders  catch  the  cord.  If  it  is 
simply  round  the  body  (Fig.  77),  the  child  escapes  through  the  loop 
as  a  rule.  The  child  '  riding '  the  cord — that  is,  '  astride  of  it ' — 
naturally  only  causes  dystocia  if  there  is  actual  shortness. 

With  shortness  of  the  cord,  in  addition  to  the  birth  of  the  child 
being  retarded,  rupture  of  the  cord,  separation  of  the  placenta,  and 
even  inversion  of  the  uterus,  may  follow.  In  the  malformed  fcetus  seen 
in  the  illustration  placenta  and  fcetus  came  away  together.  In  Hicks's 
case  a  retroplacental  haBinatoma  formed,  as  also  occurred  in  Mej'er's.3 
Matthews  Duncan4  experimented  upon  the  power  of  the  funis  to  resist 
a  breaking  strain,  and  found  it  averaged  8]  pounds,  while  the  extent 
of  elongation  before  breaking  averaged  nearly  2  inches  (5  centimetres) 
The  rupture  occurred  some  little  way  from  the  umbilicus.  But  although 
that  is  the  rule,  it  sometimes  happens  that  it  occurs  at  the  placenta, 
as  in  the  case  mentioned  by  Wynn  Williams  in  the  discussion  which 
followed  Duncan's  paper. 

1  Lond.  Obst.  Trans.,  vol.  xxiii.,  p.  253. 

2  Samml.  Klin.  Vortrdge,  No.  265,  1900. 

3  Prager  Med.  Wochenschrift,  Nos.  48  and  49  ;  ref.  Winckel's  '  Handbuch,' 
Bd.  ii.,  Heft  3,  p.  1498. 

4  Lond.  Obst.  Trans.,  vol.  xxiii.,  p.  244. 


1 II 


OPERATIVE  MIDWII  T.IlY 


Fig.  77.  —Cord  twisted  round  Body  and  Neck  of  Child. 
(From  Van  Rhyrasdyke's  drawing  in  tip  Ennterian  Minuih.  Glasgow  University.) 


The  diagnosis  of  a  short  cord  has  occasionally  been  made  before  the 
aTtual  delivery  was  in  progress,  as,  for  example,  in  McLennan's  cases. 


COMPLICATIONS  CONNECTED  WITH  THE  CORD      145 

McLennan,1  quoting Weidemann,  says  the  condition  maybe  diagnosed 
from  the  following  : 

1.  The  presence  of  the  funic  souffle. 

2.  The  recession  of  the  presenting  part  in  the  intervals  between 
the  pains. 

3.  One-sided  pain  in  the  abdomen  (Wigand). 

4.  Variability  of  the  position  of  the  head  within  narrow  limits 
(Rachel). 

5.  Discharge  of  some  blood  after  each  pain  (Rachel). 

6.  Frequent  emptying  of  the  bladder  in  the  pauses  between  the 
pains  (Brickner). 

I  can  offer  no  opinion  regarding  these  signs  and  symptoms. 
Theoretically,  they  are  self-evident,  and  I  doubt  not  are  often  present. 
How  difficult,  however,  it  must  be  to  appreciate  them  !  In  all  proba- 
bility, in  the  future,  as  in  the  past,  the  condition  will  at  earliest  be 
appreciated  when  there  is  a  difficulty  in  the  extraction  of  the  child,  or 
when  it  is  forcibly  expelled  with  a  ruptured  cord,  attached  placenta, 
or  inverted  uterus. 

When  actual  shortness  of  the  cord  exists,  the  latter  should  be 
divided,  the  child  quickly  extracted,  and  the  cut  cord  immediately 
secured.  When  the  cord  is  round  the  neck,  difficulty  in  extraction 
will  only  occur  in  head  presentations.  In  such  cases,  if  a  loop  cannot 
be  slipped  over  the  shoulder,  it  is  futile  to  try  to  bring  it  over  the 
head,  as  is  the  ordinary  procedure ;  the  cord  should  be  divided  and 
the  child  at  once  delivered.  It  is  unnecessary  to  waste  time  in  clamp- 
ing the  cord  with  pressure  forceps  or  passing  a  ligature  round  it. 

The  most  exhaustive  recent  papers  on  the  subject  of  shortness 
of  the  cord  are  by  La  Tor  re. - 

Other  abnormalities  in  the  umbilical  cord,  such  as  undue  length, 
twisting  round  the  neck,  trunk,  or  limbs,  and  knots,  have  little  effect 
upon  labour,  and  so  need  not  be  considered  in  any  detail. 

Undue  length  of  the  cord — Gottschalk  recently  recorded  one  in 
which  the  length  was  36*8  inches  (92  centimetres) — naturally  pre- 
disposes to  prolapse,  to  twistings,  and  to  the  formation  of  knots. 
Prolapse  has  been  considered  already,  and  twistings  round  the  neck 
may  lead  to  relative  shortening,  as  we  have  seen.  Occasionally  the 
cord  has  constricted  the  part  round  which  it  has  been  wound  so 
tightly  as  to  lead  to  the  death  of  the  child,  or  to  interference  with  the 
development  of  a  particular  part.  There  are  not  a  few  cases  on  record 
where  the  neck  of  the  child  has  been  extremely  constricted,  where 
the  trunk  has  been  deeply  indented,  and  where  even  a  limb  has  been 

1  '  Abdominal  Manipulations  in  Pregnane}-,'  1902,  p.  95. 

2  La  Clinica  Ostetr.,  vol.  vi.,  Nos.  1-9. 

10 


1  16 


OPERATIVE  MIDWIFERY 


amputated,  although  the  latter  condition  probably  more  often  results 
from  amnionic  bands  and  errors  of  development.  The  mosl  interest- 
ing  cases  of  knotting  are  those  in  which  two  or  more  knots  have 
occurred  in  the  cords  of  twin  foetuses  in  one  amnionic  Bac.  Such 
cases  are  very  rare.  An  example  is  seen  in  the  accompanying  illus- 
tration (Fig.  78).  Dr.  Lindsay,  of  Glasgow,  very  kindly  gave  me  the 
specimen.  The  knots,  if  they  are  tight,  invariably  lead  to  the  death 
of  the  child.  The  condition  naturally  is  only  recognized  after  the 
expulsion  of  the  placenta  and  membranes. 


Fig.   78. — Placenta  and  Knotted  Cords,  from  a  Case  of  Twin  Pregnancy. 
(Specimen  kindly  given  the  Author  by  Dr.  Lindsay.) 

The  various  anomalies  in  the  number  and  relationship  of  the 
vessels  in  the  umbilical  cord  cannot  be  considered  here.  It  is  other- 
wise, however,  with  the  insertion  of  the  cord  to  the  placenta.  The 
marginal  insertion — often  termed  '  battledore  '  placenta — is  an  abnor- 
mality occurring  in  about  5  per  cent,  of  cases.  To  a  slight  extent  it 
is  a  source  of  danger  to  the  child.  Much  more  serious,  however,  is  the 
'velamentous  insertion'  (Fig.  79),  for  in  such  cases  the  circulation  is 
very  readily  interfered  with.  Rupture  of  the  vessels  and  death  of 
the  child  from  haemorrhage  have  been  noted  on  several  occasions. 


COMPLICATIONS  CONNECTED  WITH  THE  COW)      147 

The  etiology  of  the  condition  has  been  discussed  by  Schultz, 
Kustner,  Ahlfeld,  and  others,  but,  as  it  has  no  practical  bearing, 
those  interested  in  the  matter  are  referred  to  the  monographs  on 
the  subject  by  the  authors  mentioned. 

It  is  quite  evident  why  the  child  should  suffer  in  this  condition, 


Fig.   79. — Yelamentous  Insertion  of 
Cord. 


Fi<i.  80. — Very  large  Placenta  from  a 
Case  of  Twin  Pregnancy  ;  the 
Placenta  was  Prsevia  by  reason  of 
its  Size. 


especially  if  the  placenta  is  situated  low  down  and  the  vessels  of  the 
cord  run  on  the  part  of  the  membranes  which  present. 

Levret  pointed  out  that  in  marginal  insertion  of  the  cord  the 
attachment  was  always  to  the  edge  nearest  the  os  uteri.  Barnes 
verified  this.1 

Before  rupture  of  the  membranes,  the  pulsating  vessels  may  be 
felt,  and  after  rupture  if  the  vessels  are  torn,   free   bleeding  may 

1  Lond.  Obst.  Trans.,  vol.  xxiii.,  p.  254. 


148  OPERATIVE  MIDWIPERI 

arouse  suspicion  of  the  condition.  Generally,  however,  this  abnormal 
insertion  of  the  cord  is  not  recognized  until  the  placenta  is  horn. 
fortunately,  although  rupture  of  the  vessels  may  occur,  these  ofl 
escape,  because  their  walls  are  more  resistant  than  the  membranes. 
Should  the  condition  be  recognized  during  labour,  it  is  of  impor- 
tance to  preserve  the  membranes  intact  as  long  as  possible,  and,  when 
the  os  is  sufficiently  dilated,  to  extract  the  child  immediately,  in  order 
to  prevent  it  bleeding  to  death. 

COMPLICATIONS  CONNECTED  WITH  THE  PLACENTA. 

In  connexion  with  the  placenta,  the  chief  abnormality  affecting 
labour  is  placenta  prsevia,  a  complication  which  is  considered  in 
Chapter  XXXIII.  The  various  abnormalities  in  form,  shape,  and  size 
(Fig.  80)  have  little  bearing  upon  the  subject  of  dystocia.  I  shall, 
however,  have  to  point  out  in  connexion  with  adherent  and  retained 
placenta,  that  occasionally  a  small  placenta  succenturiata  may  be  over- 
looked, and  may  give  rise  to  the  complications  which  follow  retained 
portions  of  placenta.  One  frequently  meets  with  an  abnormally  large 
placenta  in  connexion  with  malformed  and  diseased  foetuses.  In  many 
cases  it  is  ©edematous  and  adherent,  and  has  frequently  to  be  removed 
manually. 

An  interesting  complication  is  rupture  of  the  circular  sinus  of  the 
placenta,  but  as  clinically  it  resembles  placenta  praevia,  I  shall  con- 
sider it  when  the  latter  is  under  discussion. 

COMPLICATIONS  CONNECTED  WITH  THE  MEMBRANES. 

Speaking  generally,  abnormalities  of  the  membranes  are  of  patho- 
logical rather  than  practical  interest.  An  exception  might  be  made 
in  the  case  of  the  hydatidiform  mole,  which,  by  reason  of  the  dangers 
attending  its  removal  and  the  risks  of  chorion  epithelioma  following, 
is  a  condition  of  great  interest  to  the  accoucheur.  I  do  not,  however, 
propose  considering  it  here.  What  I  have  to  say  about  the  matter 
will  be  found  in  Chapter  XXXI. ,  where  abortion  is  discussed. 

Rupture  of  the  bag  of  membranes  which  dilates  the  cervix  should 
be  the  last  event  of  the  first  stage  of  labour.  Very  frequently  it 
gives  way  too  soon  or  remains  intact  too  long.  Both  occurrences 
retard  labour. 

The  premature  rupture  of  the  membranes  early  in  labour  is 
familiar  to  every  accoucheur,  and  is  usually  attributed  to  unusual 
friability  of  the  membranes.  This  is  probably  the  correct  ex- 
planation in  most  cases,  for  Matthews  Duncan1  in  his  experiments 

1  '  Researches  in  Obstetrics,'  p.  314. 


COMPLICATIONS  CONNECTED  WITH  THE  MEMBRANES  149 

found   the   resistance  of   the   membranes    to  a  bursting   force  very 
variable. 

In  this  connexion  I  have  observed  a  repetition  of  the  occurrence 
in  the  same  individual.  One  patient,  whom  I  have  attended  on  several 
occasions,  always  commences  her  labour  with  rupture  of  the  mem- 
branes. It  is  difficult,  however,  to  be  satisfied  with  the  explanation 
of  friability  in  all  cases,  for  I  have  tested  the  membranes,  and  not 
always  found  them  unusually  fragile. 


Fig.    81. — Holzapfel's   Case   of  Complete   Rupture   of  Membranes   but   Continuance   of 
Pregnancy  (Grossesse  extra niembrancuse). 


Later  in  the  first  stage  rupture  of  the  membranes  is  favoured 
by  malpresentations,  deformity  of  pelvis,  accidents,  etc. 

Early  rupture  of  the  membranes  delays  labour  and  increases 
appreciably  the  risks  to  the  child.  Dilatation  is  slower,  and  the 
uterine  contractions  often  become  irregular  and  feeble.  Indeed,  in 
some  cases  this  is  so  marked  that  the  employment  of  a  hydrostatic 
dilator  is  indicated. 

A  very  unusual  occurrence  is  for  the  membranes  to   give  way 


150  OPERATIVE  MIDWIFERY 

without  disturbing  the  pregnancy.  In  such  cases,  the  general 
explanation  given  of  the  watery  discharge  ie  an  inflammation  of 
the  decidua  (endometritis  decidnalis),  and  the  condition  is  spoken  of 
as  hydrorrhoea  gravidarum.  From  several  specimens,  however,  which 
have  been  examined  in  recent  years  it  has  become  evident  that 
rupture  of  the  membranes  may  occur  and  yet  the  pregnancy  continue. 
The  French,  who  have  given  most  attention  to  the  condition,  refer  to 
it  as  gro88es8e  extramembraneuse.  A  most  complete  paper  on  the 
subject  is  one  by  Meyer-Ruegg,1  who  describes  two  cases  in  addition  to 
those  recorded  by  others.     The  most  recent  paper  is  by  Nolle.8 

The  feature  of  this  condition,  and  the  one  wiiich  distinguishes  it 
from  the  ordinary  hydrorrhea,  is  a  sanguineous  discharge  which 
accompanies  or  follows  the  ordinary  watery  discharge  common  to 
both.  The  pregnancy  usually  terminates  prematurely,  and  the 
children,  although  many  of  them  are  born  alive,  generally  die  shortly 
after  their  birth,  for  their  growth  in  the  uterus  outside  of  the  mem- 
branes is  not  conducive  to  favourable  development.  A  case  present- 
ing all  these  features  came  under  my  notice  recently  through  the 
kindness  of  a  medical  friend.  I  give  here  a  reproduction  of  Holzapfel's 
illustration,  which  exactly  represents  the  specimen  in  my  possession. 

Bar,  Olshausen,  and  a  few  others,  have  described  cases  in  which 
the  amnion  has  given  way  early  in  pregnancy,  but  the  chorion  has 
remained  intact.  The  condition  is  recognized  after  delivery  by  the 
small  retracted  amnion.  Bar's  illustration  (Fig.  82)  reproduced  here 
shows  the  condition  very  clearly. 

The  other  condition  of  delayed  rupture  of  the  membranes  is  a 
simple  one,  and  easily  remedied.  It  may  be  overlooked,  however, 
if  there  is  little  'fore-water,'  for  then  the  membranes  may  be  closely 
applied  to  the  presenting  part  of  the  child.  Occasionally  a  casual 
observer  may  mistake  a  large  caput  succedaneum  for  the  intact 
membranes.  More  than  once  I  have  seen  this  mistake  made  by 
students,  who  have  been  trying  in  vain  to  push  a  pointed  instrument 
through  the  cedematous  swelling  on  the  child's  head.  A  macerated 
head,  and  in  a  breech  presentation  a  very  cedematous  scrotum,  and 
still  more  rarely,  and  with  even  less  excuse,  a  cystocele,  have  also 
been  mistaken  for  the  unruptured  bag  of  membranes. 

The  treatment  of  delayed  rupture  of  the  membranes  is  very  simple, 
and  consists  in  rupturing  them  during  a  uterine  contraction  with  any 
pointed  sterilized  instrument,  such  as  a  knitting-needle,  scissors,  etc. 
In  doing  this,  every  care  must  be  taken  not  to  injure  the  soft  parts 
of  the  maternal  canal.     In  cases  where  the  presenting  part  is  not 

1  Zeit.f.  Geb.  u.  G-yn.,  Bd.  li.,  Heft  3,  1904. 

2  Zent.fur  Gyn.,  Xo.  10,  1910. 


COMPLICATIONS  CONNECTED  WITH  THE  MEMBRANES   151 

engaged,  it  is  well  to  make  the  opening  in  the  membranes  small,  and 
to  keep  one's  fingers  in  the  vagina  until  the  presenting  part  becomes 
iixed,  otherwise  a  limb  or  the  cord  may  slip  down,  with  the  too  rapid 
escape  of  the  liquor  amnii. 


Fig.  82.— Early  Rupture  of  the  Amnion,  the  Chorion  remaining  Intact. 
A,  Cavity  of  amnion  ;  F,  amnionic  adhesions.     (Bar.) 

Early  in  labour  quite  another  condition  of  the  membranes  may 
retard  dilatation.  I  refer  to  adhesion  of  the  membranes  to  the  lower 
part  of  the  uterus.    This  condition  is  due  to  an  inflammatory-  condition 


152  ()l'i;i;.\TI\  !•:  MIDWIFERY 

of  the  mucous  membrane.  In  certain  cases  the  os  externum  is  com- 
pletely closed,  and  has  to  be  incised.  In  other  cases  dilatation 
proceeds  to  a  certain  extent,  and  then  ceases  ;  the  uterine  contractions 
are  too  feeble.  In  such  cases  an  attempt  should  be  made  to  separate 
the  membranes  by  sweeping  the  fore-linger  round  them,  for  it  is 
desirable  to  retain  the  membranes  intact,  if  possible.  The  subject  is 
fully  considered  in  Chapter  XIII. 

In  connexion  with  the  cases  at  present  under  discussion,  one  must 
remember  that  sometimes  the  os  externum  remains  patent  for  days 
with  the  membranes  slightly  projecting.  The  woman  sometimes 
suffers  a  good  deal  of  pain,  but  at  other  times  experiences  no  dis- 
comfort. I  have  only  seen  the  condition  in  multiparas.  It  is  often 
a  feature  of  a  protracted  or  prolonged  pregnancy.  The  cases  are 
very  troublesome  to  patient  and  doctor,  for  both  are  kept  in  continual 
expectancy  of  labour  coming  on. 

The  mortality  amongst  post-mature  fcetuses  is  very  considerable. 
So  unsatisfactory  have  been  my  results  in  two  cases  that  I  have 
determined  in  the  future  not  to  leave  this  condition  to  Nature,  but  to 
bring  on  labour  whenever  I  am  satisfied  that  pregnancy  is  certainly 
protracted. 

Should  it  be  decided  to  bring  on  labour,  the  introduction  of  a 
metreurynter  is  probably  the  best  treatment. 


CHAPTER  XI 

DYSTOCIA  THE  RESULT  OF  ABNORMALITIES  AFFECTING  THE 
PARTURIENT  CANAL 

Deformities  of  the  Bony  Canal— Classification  of  these  Deformities 
and  Consideration  of  the  Different  Varieties. 

We  come  now  to  the  third  factor  which  affects  parturition — viz.,  the 
passage. 

The  parturient  canal  consists  of  a  bony  framework  surrounding  a 
fibro-muscular  tube,  along  which  the  child  is  driven,  and  mention 
need  only  be  made  of  deformities  of  the  bony  pelvis  and  rigidity  of 
the  cervix  to  bring  to  mind  examples  of  dystocia  commonly  encoun- 
tered. But,  besides  these,  there  are  other  conditions  of  the  canal 
which,  although  less  frequently  met,  occasionally  cause  much  trouble 
in  labour.  These  are  alterations  in  the  axis  of  the  canal,  tumours  of 
its  wall  or  of  the  neighbouring  parts,  and  malformations  of  uterus 
and  vagina. 

Dystocia,  therefore,  connected  with  abnormalities  in  the  par- 
turient canal  may  be  classified  as  follows : 

A.  Deformities  of  the  bony  pelvis. 

B.  Pathological  conditions  of  the  cervix  and  vagina. 

C.  Tumours  of  uterus  and  neighbouring  organs  and  tissues. 

D.  Alterations  in  the  axis  of  the  uterus  and  vagina. 

DEFORMITIES  OF  THE  BONY  PELVIS. 

Of  all  the  conditions  in  the  parturient  canal  which  cause  dystocia, 
deformities  of  the  bony  pelvis  are  by  far  the  most  important.  Taking 
the  cases  in  the  Glasgow  Maternity  Hospital  for  the  last  five  years, 
decided  pelvic  deformity  has  been  found  present  in  fully  30  per  cent, 
of  the  indoor  patients.  This  high  proportion  is  to  be  accounted  for  by 
the  prevalence  of  rickets  in  this  city.  In  private  practice,  however, 
it  is  quite  different :  cases  of  extreme  deformity  are  rare,  and  in- 
creasingly so  as  one  ascends  the  social  scale.  They  do,  however, 
occasionally  occur,  while  minor  deformities  are  by  no  means  un- 
common, and  may  be  encountered  in  all  classes  and  grades  of  society. 

153 


154  OPERATIVE  M I DWIFERI 

It  is  quite  unnecessary  to  compare  our  figures  with  those  of  other 
hospitals  in  this  and  other  countries,  for,  speaking  generally,  although 
there  are  many  varieties  of  pelvic  deformity  other  than  those  produced 
by  rickets,  the  prevalence  of  rickets  in  a  city  is  an  index  of  the  amount 
of  pelvic  deformity  to  be  expected.  An  exception  might  perhaps  he 
made  for  the  I thine,  North  Italy,  and  some  other  areas  in  Europe,  where 
osteomalacia  is  prevalent,  and  where  deformities  resulting  from  that 
disease  are  more  commonly  encountered  than  any  other. 

In  considering  the  etiology  and  features  of  the  various  forms  of 
pelvic  deformity,  it  would  be  quite  out  of  place  in  these  pages  to  go 
into  any  detail.  We  are  really  concerned  with  the  means  of  over- 
coming the  difficulties.  I  shall,  therefore,  only  briefly  refer  to  the 
general  features  and  characteristics  of  the  abnormalities. 

The  two  principal  factors  which  influence  pelvic  deformity  are 
errors  of  development,  and  disease  of  the  pelvic  bones  and  joints.  As, 
however,  alterations  in  the  spinal  curves  and  set  of  the  lower  limbs 
may  affect  the  direction  of  the  forces  transmitted  through  the  pelvis 
while  it  is  still  growing,  it  is  sometimes  found  that  pelvic  deformity 
is  produced  or  aggravated  by  abnormalities  in  spine  and  lower  limbs. 

Various  attempts  have  been  made  to  classify  pelvic  deformities 
since  Deventer's  time.  Michaelis  and  Litzmann1  based  their  arrange- 
ments upon  alterations  in  shape,  and  disregarded  etiology  altogether. 
Schauta'2  was  the  first  to  give  a  really  simple  classification  based  upon 
etiological  factors.  Breus  and  Kolisko:!  have  slightly  modified  Schauta's 
arrangement,  and,  on  the  whole,  improved  it,  especially  if  they  had 
omitted  the  fifth  group,  which,  with  a  little  stretch,  may  be  included 
in  the  second.  With  a  view  to  making  the  classification  as  simple  as 
possible,  I  would  venture  to  suggest  the  following  : 

I.  Deformities  resulting  from  faulty  development :  (a)  Justo-major 
pelvis  (pelvis  simpliciter  seu  equabiliter  justo-major)  ;  (M  justo-minor 
pelvis  (pelvis  equabiliter  justo-minor)  or  generally  contracted  pelvis  ; 
(c)  simple  flat,  non-rachitic  pelvis ;  (d)  Naegele's  pelvis,  imperfect 
development  of  one  sacral  ala  (Breus  and  Kolisko  place  this  in  the 
group  where  the  deformity  is  the  result  of  disease  in  the  bones  and 
joints  ;  but  the  ankylosis  is  secondary,  as  a  rule,  to  the  imperfect 
development  of  the  ala?,  and  so  I  place  it  here,  as  Schauta  does)  ; 
(e)  Koberts' pelvis,  imperfect  development  of  both  sacral  ala? ;  (/)  split 
pelvis,  imperfect  development  of  pubes  ;  (fi)  assimilation  pelvis. 

II.  Deformities  resulting  from  disease  of  the  pelvic  bones  and 
joints:   (a)  Rickets  ;   (A)  osteomalacia  ;  (c)  new  growths  ;  (<1)  fractures  ; 

1  '  Das  engc  Beckon,'  p.  267,  1851. 

-  Muller's  '  Handbucb  der  Geburtshiilfe,'  Bd.  ii..  1889,  p.  207. 

3  'Die  Patholotfisehen  ]5eekenformen,'  1900. 


DEFORMITIES  OF  THE  BONY  PELVIS  155 

(e)  atrophy,  caries,  and  necrosis  ;  (/)  disease  of  sacro-iliac,  pubic,  and 
sacro-coccygeal  joints. 

III.  Deformities  resulting  from  disease  in  spinal  column  : 
(a)  Kyphosis  ;  (b)  scoliosis  ;  (c)  spondylolisthesis. 

IV.  Deformities  resulting  from  disease  of  the  lower  extremities  : 
(a)  Coxitis  ;  {b)  dislocation  of  one  or  both  femurs  ;  (c)  atrophy  or  loss 
of  one  or  both  limbs. 

I.  Deformities  resulting  from  Faulty  Development. 

Justo-Major  Pelvis. — This  pelvis  in  its  -extreme  form,  which  is 
very  rare,  is  found  in  giants.  Moderate  degrees  of  the  condition  are 
occasionally  encountered,  and  not  always  amongst  those  of  unusual 
height  or  physique.  A  roomy  pelvis  renders  the  passage  of  the  head 
more  easy,  and  favours  precipitate  labour. 

Justo-Minor  or  Generally  Contracted  Pelvis. — This  is  a  variety 
of  pelvic  deformity  which  is  by  no  means  uncommon,  and  often  occurs 
quite  unexpectedly  in  private  practice.  The  term  implies  that  the 
pelvis  is  equally  deformed  in  all  its  diameters,  and  in  slight  degrees  it 
is  so,  but  in  the  more  marked  there  is  usually  a  relatively  greater 
diminution  of  the  antero-posterior  or  of  the  transverse  diameters. 

It  is  commonly  stated  that  the  existence  of  the  generally  contracted 
pelvis  should  be  suspected  in  women  of  very  small  stature  in  whom  there 
is  no  evidence  of  rickets.  Although  this  is  correct  on  the  whole,  it  is 
sometimes  misleading,  for  the  deformity  is  often  present,  and  sometimes 
in  quite  a  distinct  degree,  in  women  of  ordinary  height  and  physique. 

By  pelvimetry  the  interspinous,  intercristal,  and  external  and 
oblique  conjugate  diameters  are  found  decreased,  but  proportionately 
so.  By  vaginal  examination  the  promontory  can  be  reached,  but  it 
does  not  project  as  in  flat  pelvis.  The  deformity  continues  right  down 
through  the  cavity. 

On  pushing  the  head  into  the  pelvis,  if  the  pregnancy  has  reached 
term,  there  is  more  or  less  overlapping  of  the  head  at  the  brim.  At 
the  commencement  of  labour,  even  in  primiparae,  the  head  is  still 
movable,  unless  the  latter  is  unusually  small. 

The  mechanism  of  labour  is  quite  characteristic,  the  feature  being 
a  marked  increase  of  flexion  (Fig.  1G),  caused  by  the  increased  resist- 
ance offered  to  the  head.  The  head  invariably  enters  in  the  oblique 
diameter.  As  a  result  of  this  the  posterior  fontanelle  can  be  reached 
with  extreme  ease.  The  labour  is  retarded  in  proportion  to  the 
deformity  of  the  pelvis  and  the  size  of  the  fcetal  head. 

Uterine  inertia  not  infrequently  occurs,  and  delivery  has  often  to 
be  completed  by  forceps,  or  even  by  some  of  the  major  obstetric 
operations.     In  the  non-rachitic  generally  contracted  variety  the  de- 


156 


OPERATIVE  MIDWIFERY 


forniity  is  not  often  so  great  that  Cesarean  section  or  craniotomy  is 
necessary.  With  the  generally  contracted  rachitic  form  it  is  quite 
otherwise — these  operations  are  often  called  for.  Walcher'e  position, 
so  great  a  help  in  flat  pelvis,  is  of  no  value  in  facilitating  the  passage 
of  the  head  through  the  brim.     Version  is  absolutely  contra-indicated. 


FlG.   S3. — Funnel-shapt.-d  l'elvis. 

There  are  several  subdivisions  of  the  generally  contracted  pelvis. 
Of  course,  the  most  common  is  the  '  masculine  pelvis,'  in  which  the 
bones  are  strong  and  thick.  In  addition  to  the  deformity  at  the  brim, 
there  is  a  marked  diminution  in  the  capacity  of  the  outlet,  the  sub- 
pubic angle  being  more  acute.  The  pelvis  becomes  '  funnel  '-shaped, 
and  is  often  referred  to  under  that  name  (Fig.  83).     In  such  a  pelvis 


FlG.    B4.— Infantile  Pelvis. 

the  greatest  difficulty  in  the  delivery  may  be  at  the  outlet.  Another 
form  is  the  '  true  dwarf  pelvis.'  In  this  variety  the  general  pelvic 
development  is  much  retarded,  and  in  certain  forms  the  epiphyseal 
cartilages  are  not  ossified.  Lastly,  there  is  the  '  infantile  pelvis  ' 
(Fig.  84),  in  which  the  pelvis  retains  the  infant  form.  The  bones 
are  small,  the  sacrum  is  narrow,  and  the  antero-posterior  diameter  is 


DEFORMITIES  OF  THE  BONY  PELVIS  157 

greater  than  the  transverse.  Pregnancy  in  the  extreme  degrees  of  the 
true  dwarf  and  infantile  pelvis  rarely  occurs. 

Flat  Non-Rachitic  Pelvis. — In  this  pelvis  the  antero-posterior 
diameter  is  diminished  down  through  the  pelvis,  the  whole  sacrum 
being  placed  farther  forward.  The  promontory  does  not  project  so 
markedly  as  in  the  rachitic  form,  and  there  is  often  a  false  pro- 
montory at  the  junction  of  the  first  and  second  sacral  vertebrse.  The 
transverse  and  oblique  diameters  remain  the  same,  or  may  even  be 
slightly  increased. 

Although  referred  to  by  many  as  being  a  comparatively  common 
deformity,  it  is  very  questionable  if  it  really  is.  I  believe  that  most 
of  the  so-called  flat  pelves  have  had  their  origin  in  rickets,  and  this 
view   is    being   gradually   more   favoured.      The   carrying   of   heavy 


Fig.  85. — Obliquely  Contracted  Pelvis.     (Xaegele.) 

weights  as  a  cause  cannot  be  traced.  This  pelvis  is  found  in  indi- 
viduals who  apparently  are  perfectly  normal  and  healthy,  and  have 
always  been  so.  Fehling  maintains  that  the  deformity  is  congenital 
in  many  cases. 

The  diagnosis  of  this  variety  of  pelvic  deformity  is  not  difficult. 
The  promontory  and  whole  sacrum  is  easily  reached,  and  it  is  dis- 
tinguished from  the  rachitic  variety  by  the  absence  of  the  ordinary 
features  of  rickets,  and  by  the  flatness  of  the  sacrum.  The  mechanism 
of  birth  is  the  same  as  in  the  flat  rachitic  pelvis. 

Obliquely  Contracted  or  Naegele  Pelvis. — This  somewhat  rare 
variety  of  pelvic  deformity  (Fig.  85)  is  produced  by  an  arrested 
development  of  one  ala  of  the  sacrum.  There  follows  from  this  an 
alteration  in  the  spinal  and  pelvic  curves,  and  almost  invariably  an 
ankylosis  of  the  sacro-iliac  joint.  From  the  increased  weight  thrown 
upon  the  affected  side,  that  side  as  a  whole  is  raised  and  pushed 


158  OPERATIVE   MIDWIFERY 

backwards  and  inwards.     Bui  1  lie  most  striking  feature  is  the  straight- 
ening of  the  ilio-pectineal  line  on  the  affected  side.     The  symphysis  is 
pushed  ;m  inch  or  more  beyond  the  middle  line.     The  transverse  and 
longitudinal  diameters  are  very  little  affected,  but  the  oblique  is  \ 
decidedly  diminished. 

The  difficulty  in  labour  arises  from  the  sacral  '  bay  '  on  the  affected 
side  being  of  little  value,  as  it  can  rarely  accommodate  any  part  of 
the  foetal  head.  Indeed,  for  all  practical  purposes  the  pelvis  is 
extremely  contracted. 

As  a  rule  the  ordinary  pelvic  measurements  throw  little  light  upon 
the  deformity,  and  the  appearance  of  the  patient  is  not  characteristic, 
so  that  it  is  often  not  appreciated  until  labour  is  in  progress.     The 


Fig.  86. — Transversely  Contracted  Pelvis.     (Huberts. ) 

measurements  which  should  be  taken  are  measurements  between  the 
symphysis  and  the  posterior  superior  spines,  between  the  spinal 
column  and  the  posterior  spines,  and  between  the  anterior  superior 
spine  and  the  opposite  posterior  superior  spine.  The  measurement 
of  the  two  sides  should  be  compared,  and,  if  a  difference  of  more  than 
I  inch  be  found,  then  an  oblique  deformity  may  be  assumed. 
Cesarean  section  or  craniotomy  are,  as  a  rule,  the  only  alternatives 
in  the  way  of  treatment,  for  the  results  from  forceps  delivery  have 
been  very  unsatisfactory. 

Transversely  Contracted  or  Roberts'  Pelvis. — This  has  some- 
times been  referred  to  as  a  double  Naegele  pelvis,  for  both  ahe  of  the 
sacrum  are  more  or  less  ill-developed.  The  deformity  may  be 
symmetrical  or  more  accentuated  on  one  side  (Fig.  86).  It  is  the 
rarest  of  all  the  pelvic  deformities.  As  the  cavity  throughout  is  so 
very  much  narrowed  transversely,  it  is  impossible  to  deliver  a  living 


DEFORMITIES  OF  THE  BONY  PELVIS 


159 


child  per  vias  naturales ;  consequently,  Cesarean  section  is  the  only 
treatment  if  the  child  is  alive. 

Split  Pelvis. — This  variety  is  extremely  rare  in  ohstetric  practice, 
being  commonly  associated  with  ectopia  of  the  bladder  and  other 
malformations  of  the  generative  and  urinary  organs.  The  pubic 
bones  may  be  separated  as  much  as  4  inches  ;  they  are  united  by 
iibrous  tissue.  The  transverse  diameters  are  increased.  A  most 
interesting  case  of  labour  in  such  a  pelvis  has  been  described  by 
Adam1  of  Hamilton  (Figs.  87  and  88).  There  are  only  some  dozen 
similar  cases  on  record. 


Fig.   87.— Split  Pelvis. 

{From  a  drawing  by  Dr.  J.  Lindsay  of  the  case  recorded  by  Dr.  Adam  of  Hamilton.,  and 

kindly  lent  the  Author. ) 

Assimilation  Pelvis.  —  There  are  here  figured  two  forms  of 
assimilation  pelvis.  In  one  the  sacrum  consists  of  four  (Fig.  89)  and 
in  the  other  of  six  fused  vertebrae  (Fig.  90).  Such  departures  from 
the  normal  are  rarely  recognized  during  life,  and  are  of  no  obstetric 
interest. 

II.  Deformities  the  Result  of  Disease  of  the  Pelvic  Bones 

and  Joints. 

In  this  country,  and  in  temperate  climates  generally,  rickets  is 
the  chief  factor  in  the  causation  of  pelvic  deformities.     But  although 
1  Journ.  Obstet.  and  Gyn.  Brit.  Empire,  vol.  ii.,  October,  1902,  p.  3771. 


160 


OPERATIVE  MIDWI!  i:i;V 


rickets  is  so  generally  distributed  over  the  continents  of  both  Europe 
and  America,  it  is  more  prevalent  in  certain  countries  than  in  others, 
and,  speaking  generally,  it  is  a  disease  of  large  cities.  Glasgow 
possesses  the  unenviable  distinction  of  being  one  of  the  cities  in 
which  the  disease  is  especially  common.  As  giving  some  idea  of  the 
prevalence  of  the  disease,  I  have  already  mentioned  that  of  the  women 
treated  in  the  Glasgow  Maternity  Hospital  over  80  per  cent,  have 
distinctly  deformed  pelves. 


-Umbilical  Area. 


^-Vesical  Area. 

-Right  Labium  Minus 
-Left    Labium    Minus 

^■Cervix  Uteri 


Fig. 


-Outline  Drawing  of  Same  Case. 


Deformities  the  Result  of  Rickets. — In  obstetric  practice  one 
meets  with  three  varieties  of  pelvic  deformity  the  result  of  rickets : 
(a)  Flat  rachitic  pelvis;  (6)  generally  contracted  rachitic  pelvis,  usually 
also  flat ;  (r)  pseudo-malacosteon  pelvis. 

The  Flat  Rachitic  Pelvis. — This  is  the  commonest  variety  of 
pelvic  deformity  produced  by  rickets.  In  order  to  understand  it 
properly,  one  must  think  of  the  time  when  the  child  was  the  subject 
of  the  disease.  Rickets  affects  children  most  commonly  during  the 
second  year,  when  the  child  is  either  sitting  or  attempting  to  walk,  or 
if  very  ill,  is  lying  or  sitting  in  bed.  In  the  latter  position  the  weight 
of  the  trunk   is  transmitted   through   the   pelvis  on    to  the  ischial 


DEFORMITIES  OF  THE  BONY  PELVIS  161 

tuberosities,  and  the  pelvic  bones,  being  softened  by  disease,  are 
deformed  as  follows  :  The  promontory  of  the  sacrum,  owing  to  the 
weight  of  the  trunk,  is  displaced  downwards  and  forwards,  and  the 
obliquity  at  the  brim  is  frequently  increased.  This  would  naturally 
cause  a  tilting  back  of  the  lower  part  of  the  sacrum  and  coccyx,  were 


Fig.  89. — Low  Assimilation  Pelvis.     (Breus  and  Kolisko.) 

it  not  that  the  sacro-sciatic  ligaments  and  muscles  of  the  pelvic  floor 
prevent  it,  causing  a  sharp  bending  of  the  sacrum  at  the  level  of  the 
fourth  and  fifth  sacral  vertebral.  Very  occasionally  the  curve  is 
obliterated,  and  the  sacrum  and  coccyx  are  quite  straight  and  flat. 
The  upper  part  of  the  sacrum  is  usually  flattened.     With  the  sinking 


Fig.  90. — High  Assimilation  Pelvis.     (Breus  and  Kolisko.) 

of  the  promontory  the  posterior  spinous  processes  are  dragged  closer 
by  the  sacro-iliac  ligaments,  and  this  and  the  dragging  and  flattening 
of  the  anterior  pelvic  wall  causes  a  relative  increase  of  the  inter- 
spinous  as  compared  with  the  intercristal  diameter.  The  former, 
instead  of  being  about  f  inch  less,  may  be  the  same  as,  or  even  greater 
than,  the  latter.     Further,  as  a  result  of  the  flattening  of  the  anterior 

11 


162  OPERATIVE  MIDWIFERY 

wall,  the  acetalmla  come  to  look  more  forward,  and  if  the  hones  are 
still  soft  when  the  child  goes  ahout,  this  may  he  increased.  All  tlii- 
causes  a  sharp  bending  of  the  ilio-pectineal  line.  But  there  is  still 
another  striking  feature.  The  tuberosities  of  the  ischia,  on  which  the 
child   sits,  yield,  and   are  pressed  farther  out,  so  that   there  is  an 


FIG.  91.— Flat  Rachitic  Pelvis. 

increase  of  the  distance  between  these  two  points  and  a  widening  of 
the  subpubic  angle,  and,  in  consequence,  increase  of  the  transverse 
diameter  of  the  outlet. 

Looking  at  the  pelvis  from  the  inside,  one  finds  the  promontory  of 
the  sacrum  unusually  distinct,  sometimes  very  pointed,  at  other  times 


Fig.  92.— Flat  Rachitic  Pelvis — Brim  ahowing  an  Outline  resembling  a 
Figure  of  Eitjlit. 

more  blunt,  and  this  gives  to  the  brim  a  reniform  outline  (Fig.  91). 
In  addition,  if  the  anterior  wall  at  the  symphysis  is  dragged  in  by  the 
action  of  the  muscles  on  the  softened  brim — and  these  latter  come 
into  strong  action  if  the  child  is  sitting — the  brim  assumes  a  figure- 
of-eight  form  (Fig.  i»2).1 

1  According  to  Kehrer,  the  muscles  acting  on  the  softened  bones  play  the  most 
important  part  in  producing  the  deformities  described. 


DEFORMITIES  OF  THE  BONY  PELVIS  L63 

If  there  is  any  marked  lateral  spinal  curvature,  a  further  deformity 
results ;  the  promontory  is  pushed  over  to  the  side,  and  one  gets  the 
scolio-rachitic  pelvis  (Fig.  93).  This  latter  form  I  have  found  much 
more  common  than  is  usually  stated,  for  frequently  it  is  only  slightly 
marked  and  difficult  of  recognition.  In  some  cases  it  is  very  distinct, 
and  interferes  greatly  with  the  passage  of  the  foetal  head  through 
the  brim — indeed,  in  extreme  cases  one  side  may  be  so  shut  off  as  to 
be  of  no  service. 

This  flattening  of  the  pelvis  produces  a  narrowing  of  the  antero- 
posterior diameter,  or  conjugata  vera.  I  have  seen  it  as  small  as 
1]  inches  (3  centimetres).  The  effect  on  the  transverse  diameter  at 
the  brim  depends  upon  whether  or  not  there  has  been  any  arrest  of 
the  general  development  of  the  pelvis.     If  the  disease  was  only  slight, 


Fig.  93.— Seolio-Rachitic  Pelvis. 

the  transverse  diameter  remains  about  the  same,  although  it  is  stated 
that  there  is  sometimes  an  actual  increase.  I  have  seldom,  however, 
found  any  distinct  increase,  and  invariably  when  the  flattening  is 
decided  the  transverse  diameter  is  also  diminished. 

A  peculiarity  not  infrequently  seen  is  a  false  promontory.  There 
are  two  varieties  of  false  promontory — one  where  the  last  lumbar 
vertebra  is  pushed  downwards  and  forwards,  and  the  other  where 
the  first  and  second  sacral  vertebrae  project  unduly.  They  are  often 
termed  '  high  '  and  '  low '  false  promontories  respectively.  They  are 
by  no  means  uncommon,  and  are  often  overlooked  or  not  recognized. 
Their  importance  is  that  the  measurement  from  them  to  the  symphysis 
may  be  less  than  the  true  conjugate,  and  so  the  real  difficulty  to  the 
head  passing  through  the  brim  may  be  above  or  below  the  true  brim. 
I  may  say  in  passing,  what  is,  of  course,  self-evident,  that,  other 


nil  <>ri. i;.\tiyi:  midwifery 

things  being  equal,  a  high  false  promontory  is  more  serious  than 
a  low  one. 

Passing  from  the  brim  to  the  cavity,  one  finds  that  the  Latter  ie 

usually  shallow  and  roomy.  In  Hat  rachitic  pelvis,  therefore,  it  may 
be  safely  said  that  once  the  head  gets  through  the  brim  it  is  seldom 
arrested  in  the  cavity.  At  the  outlet  there  may  be  sometimes  a  little 
difficulty,  for,  although  the  transverse  diameter  is  increased,  the 
dragging  of  the  coccyx  inwards  may  diminish  the  conjugate  to  a 
Blight  extent. 

In  the  mechanism  of  labour  in  flat  pelvis,  either  rachitic  or  non- 
rachitic, there  are  three  characteristic  features  : 

1.  The  head  engages  in  the  transverse  diameter. 

2.  The  head  is  less  flexed. 

3.  The  biparietal  obliquity  is  more  marked. 

It  is  only  natural  that  the  head  should  pass  through  the  brim  in  the 
transverse  diameter,  which  is  so  much  the  largest.  If  examined  at  this 
stage,  the  anterior  fontanelle  can  always  be  readily  reached,  and  is 
usually  lower,  although  occasionally  it  may  be  at  the  same  level  as  the 
posterior.  But  the  most  striking  alteration  in  attitude  is  the  increased 
parietal  obliquity.  The  head  is  tilted  towards  one  or  other  shoulder, 
with  the  result  that  the  anterior  or  posterior  parietal  bone  presents. 

In  the  anterior  parietal  presentation  (asynclitismus  anterior, 
Fig.  94)  the  parietal  bone,  directed  posteriorly,  is  arrested  by  the 
promontory  of-  the  sacrum.  It  is  an  exaggerated  degree  of  what  is 
termed  '  Naegele's  obliquity.'  The  birth  takes  place  by  the  anterior 
parietal  bone  becoming  pressed  against  the  anterior  wall  of  the 
pelvis,  and  the  posterior  being  driven  down  round  the  promontory. 
It  is  a  very  much  more  favourable  position  than  the  posterior ; 
indeed,  in  a  large  number  of  cases  one  sees  spontaneous  delivery 
occur. 

In  the  posterior  parietal  presentation  (asynclitismus  posterior, 
Fig.  95)  Litzmann's  obliquity  is  exaggerated,  and  it  is  the  anterior 
parietal  bone  that  is  arrested  at  the  symphysis,  while  the  posterior 
engages  at  the  brim.  The  mechanism,  according  to  Litzmann,  was 
for  a  gradual  correction  to  take  place,  but  Veit  showed  that  the  head 
might  pass  through  the  pelvis  by  the  anterior  parietal  bone  becoming 
much  moulded  and  forced  past  the  symphysis.  Spontaneous  delivery 
is  difficult  in  such  a  presentation,  unless  the  pelvis  is  only  slightly 
deformed.  A  posterior  parietal  presentation  should  always  arrest 
attention,  for  not  only  is  the  presentation  particularly  unfavourable, 
but  the  degree  of  pelvic  deformity  is  usually  considerable  when  the 
head  assumes  this  attitude. 


DEFORMITIES  OF  THE  BONY  PELVIS  165 

I  have  repeatedly  tried  to  correct  a  posterior  into  an  anterior 
parietal  presentation  after  rupture  of  the  membranes,  but  so  far 
with  little  success ;  and  this  is  the  general  experience.  If  the  pelvic 
deformity  is  not  too  great,  version  is  recommended  by  many,  and 
certainly  it  has  always  appeared  to  me  sound  treatment.     The  only 


Fig.  94. — Anterior  Parietal  Presentation. 

difficulty  in  pursuing  such  a  course  is  that  the  position  is  often  only 
recognized  some  time  after  the  membranes  have  ruptured. 

When  version  is  impossible,  and  the  natural  forces  fail  to  overcome 
the  difficulty,  the  forceps  is  of  little  value  unless  the  head  is  well  fixed 
and  the  pelvis  only  very  slightly  deformed.  Craniotomy  is  then  the 
only  course  open  if  the  child  is  dead,  and  symphysiotomy,  pubiotomy, 
or  Cesarean  section  if  it  is  alive. 


L66  OPERATIVE  MIDWIFERY 

Generally  Contractu])  Rachitic  Pelvis. — The  majority  of  the 
cases  of  marked  pelvic  deformity  come  under  this  beading.  The  hones 
are  small  and  hard.  In  an  absolutely  typical  example  flattening  is 
absent,  hut  in  actual  practice  one  invariably  finds  flattening,  as  well 
as  general  contraction.  The  explanation  of  the  deformity  is  that  the 
disease  has  arrested  the  pelvic  development.     The  patients  may  he 


FlG.  95. — Posterior  Parietal  Presentation 


very  small  and  much  deformed  in  limbs,  chest,  etc.  It  has  heen 
already  explained  that  a  general  contraction  of  the  pelvis  is  much 
more  serious  than  simple  flattening.  Roughly,  one  calculates  that 
a  generally  contracted  pelvis  of,  say,  8|  inches  (8*1  centimetres)  is 
equal  to  a. flat  pelvis  of  8  inches  (7*5  centimetres),  hut  when  the 
conjugate  falls  below  that  figure,  the  difference  is  even  greater. 


DEFORMITIES  OF  THE  BONY  PELVIS  1(57 

Pshudo-Malacosteon  Rachitic  Pelvis.  —  This  variety  of  pelvic 
deformity  is  very  rare.  As  far  as  I  can  remember,  I  have  only  seen 
two  typical  examples.  Its  features  will  be  understood  from  the  illustra- 
tion (Fig.  90).  Presumably  it  occurs  when  the  disease  has  run  a  long 
course,  and  when  it  has  attacked  the  walking  child.  As  a  natural 
consequence,  the  weight  of  the  child  being  supported  by  the  femora, 
instead  of  the  ischial  tuberosities,  the  sides  of  the  pelvis  are  pushed 
in,  and  the  anterior  wall  projects  in  the  form  of  a  beak.  A  similar 
deformity  is  seen  in  the  malacosteon  pelvis,  only  to  a  more  marked 
extent,  and  hence  the  term  '  pseudo-malacosteon  pelvis '  given  to  this 
variety  of  rachitic  deformity. 

Osteomalacic  Pelvis. — This  is  a  deformity  of  the  pelvis  the 
result  of  the  disease  mollities  ossium  or  malacosteon.     The  disease  is 


Fig.  96. — Pseudo-Malacosteon  Pelvis. 

one  of  adult  life,  and  attacks  both  sexes,  although  women  are  affected 
ten  or  twelve  times  as  often  as  men.  In  women  it  is  confined  almost 
entirely  to  multipara  in  the  period  of  life  when  the  reproductive 
organs  are  functionating.  It  is  specially  active  during  pregnancy 
and  the  puerperium.  A  most  interesting  feature  of  the  disease  is  the 
fact  that  it  is  prevalent  only  in  certain  localities.  In  England, 
America,  and  France,  for  example,  it  is  extremely  seldom  seen,  whiif; 
in  such  areas  as  the  Rhine  Valley,  the  North  of  Italy,  and  certain 
districts  of  Switzerland  and  Hungary,  it  may  be  said  to  be  endemic. 
Almost  certainly  it  is  a  disease  of  unsatisfactory  housing  and  improper 
and  defective  feeding,  but  one  would  think  that  there  must  be  some- 
thing more  than  that,  for  similarly  unhealthy  conditions  exist  in  all 
countries. 

A  most  important  contribution  to  the  etiology  and  treatment  of  the 
disease  was  made  by  Fehling  in  1888,  when  he  pointed  out  the  great 


168  OPERATIVE  MIDWIFERY 

benefit  that  follows  oophorectomy.  To  speak  of  the  disease,  however, 
as  a  '  trophoneurosis,' and  caused  by  a  pathological  condition  in  the 
ovarian  secretion,  is  somewhat  premature,  as  our  knowledge  of  the 
ovarian  secretion  is  still  very  incomplete.  At  present  only  this  fact 
is  known — that  oophorectomy  does,  in  many  cases,  decidedly  arrest 
the  progress  of  the  disease. 

The  onset  of  the  disease  is,  as  a  rule,  gradual.  During  the  course 
of  a  pregnancy,  usually  after  one  or  two  normal  pregnancies,  pains 
are  complained  of  in  the  back  and  limbs,  and  walking  becomes 
irksome.  These  symptoms  may  disappear  after  labour  and  lactation, 
to  return  again  with  increased  severity  in  a  subsequent  pregnancy. 
With  each  pregnancy  locomotion  becomes  more  awkward,  the 
patient's  stature  becomes  less,  from  sinking  of  the  trunk,  and  the 


Fig.  97. — Osteomalacic  1'elvis  (Anterior  View  . 

labours  become  more  and  more  difficult  from  the  narrowing  of  the 
bony  canal. 

The  bones,  as  a  result  of  the  softening,  bend,  according  to  the 
direction  of  the  forces  transmitted  through  them.  The  illustrations 
(Figs.  97,  98)  give  a  fairly  good  idea  of  the  malformations  that  result 
from  the  disease,  and  it  may  be  remarked  that  in  no  pathological 
condition  of  the  pelvis  does  one  meet  with  such  extreme  deformity  as 
in  osteomalacia.  The  promontory  being  pushed  downwards  and  for- 
wards, and  the  lateral  pelvic  walls  inwards,  cause  the  anterior  wall  to 
be  pushed  out  in  the  form  of  a  beak,  and  the  brim  to  assume  a 
trifoliate  shape.  Hence  the  pelvis  is  often  spoken  of  as  the  '  beaked,' 
'rostrate,'  or  '  triradiate '  pelvis.  The  subpubic  arch  is  very  much 
narrowed,  from  the  approximation  of  the  ischial  tuberosities.  The 
acetabula  look  more  forward,  and  the  legs  are  brought  closer  together, 
so  that  the  subjects  of  the  disease  have  a  peculiar  swinging  gait. 
From  the  muscles  and  ligaments  dragging  on  their  attachments,  a 
marked  curving  of    the  iliac  crests,  and  posterior  parts  of   the  in- 


DEFORMITIES  OF  THE  BONY  PELVIS       109- 

nominate  bones,  results,  so  that  the  posterior  spinous  processes  may 
almost  touch  (Fig.  98). 

The  diagnosis  of  this  variety  of  pelvic  defomiity  is  not  difficult. 
The  history  of  the  disease  and  the  deformities  produced  are  absolutel  v 
characteristic. 

Prior  to  Fehling's  discovery  that  oophorectomy  had  such  a  bene- 
ficial effect  upon  the  disease,  the  salts  of  lime  and  phosphorus  in 
various  forms  were  most  strongly  recommended.  The  results  obtained 
from  such  drugs,  however,  were  not  very  satisfactory. 

As  a  result  of  Fehling's  discoveries,  Csesarean  section,  with  removal 
of  uterus  and  ovaries,  is  the  treatment  to  be  adopted  in  all  pronounced 
examples  of  the  disease.  In  the  slighter  forms  of  the  disease  other 
simpler  methods  of  treatment  may  prove  sufficient,  but  owing  to  the 


Fig.  98. — Osteomalacic  Pelvis  (Posterior  View). 

nature  of  the  deformity  it  can  be  readily  understood  that  it  does  not 
require  any  great  malformation  to  render  delivery  j>er  rias  naturales- 
impossible. 

New  Growths. — Small  osteomata  (pelvis  spinosa),  more  especially 
about  the  symphysis,  sacro-iliac  synchondrosis,  and  the  ilio-pectineal 
eminences,  are  not  very  uncommon.  Such  small  growths,  if  the 
pelvis  is  contracted,  may  cause  injuries  to  the  foetal  head,  such  as 
gutter-shaped  indentations  and  fractures  (Chapter  XXXVIII.),  or 
lacerations  of  the  uterus  from  the  pressure  of  the  head. 

Larger  tumours  (Fig.  99) — osteomata,  enchondromata,  fibro- 
mata— are  only  very  occasionally  encountered.  In  the  last  six 
years,  in  the  Maternity  Hospital,  we  have  only  had  one  case, 
recorded  by  Jardine.1  With  the  exception  of  the  osteomata,  they 
are  frequently  malignant,  most  commonly  sarcomatous.  They  are 
usually  situated  on  the  posterior  wall  in  the  neighbourhood  of  thf* 

1  Journ.  Obst.  and  Gyn.  Brit.  Empire,  vol.  ii.,  1902.  p.  147. 


L70  Ol'KliATIVK   .M  1 1  >\VJ  I- 'EB  V 

-aero-iliac  synchondrosis.  Naturally,  such  tumours  prevent  the 
passage' of  the  child  through  the  pelvis,  and  so  Cfflsarean  section 
is  invariably  necessary. 

Fractures  of  Pelvis.— As  can  be  readily  understood,  fractures, 
•either  from  the  amount  of  callus,  or  from  the  irregular  anion  of 
the  fractured  portions,  may  occasionally  produce  a  deformity  of  the 
pelvis,  and  cases  of  this  nature  have  been  described.     The  deformities 


Fig.  99. — Sacral  Tumours.     iBiinuu.) 

are  very   seldom  encountered,   for  fractures  of  the  pelvis   generally 
result  in  death. 

Caries  and  Necrosis  of  the  Pelvis. — In  the  rare  cases  in  which 
the  acetabulum  becomes  perforated  in  hip-joint  disease,  there  may 
result  an  irregular  bony  formation,  which  may  encroach  upon  the 
lateral  pelvic  wall.  The  effect  of  hip-joint  disease  on  the  pelvis  we 
shall  consider  later.  Caries  of  the  sacro-iliac  joint  may  result  in  an 
ankylosis  of  the  joint,  and  the  development  of  one  sacral  ala  may  be 
arrested  in  consequence.  In  such  cases  an  obliquely  contracted  pelvis, 
resembling  Naegele's,  results. 


DEFORMITIES  OF  THE  BONY   PELVIS  171 

Diseases  of  the  Sacro-Iliac,  Pubic,  and  Sacro-Coccygreal  Joints. 

— 1  have  referred  already  to  the  effect  of  disease  and  ankylosis  of  the 
sacro-iliac  joint.  Ankylosis  of  the  pubic  joint  is  by  no  means  common, 
and  some  operators  who  have  performed  many  symphysiotomies 
•question  its  occurrence.  Reference  will  be  made  to  this  when  sym- 
physiotomy is  under  discussion. 

As  regards  the  coccygeal  joint,  premature  ankylosis,  or  ankylosis 
following  fracture,  may  cause  obstruction  to  the  escape  of  the  child's 
head.  Removal  of  the  coccyx  is  the  correct  and  most  scientific  treat- 
ment. The  general  course  followed  is  to  pull  the  child  past  the 
■obstruction  with  forceps  and  refracture  the  bone. 


III.  Deformities  resulting  from  Disease  in  the  SpiNx^l  Column. 

Kyphosis. — The  deformity  of  the  pelvis  found  in  kyphosis  depends, 
in  great  part,  upon  the  degree  and  situation  of  the  curvature.  It  is 
also  influenced  by  the  age  of  the  individual,  and  the  disease,  tubercu- 
losis or  rickets,  which  causes  the  deformity.  In  cases  where  there  is 
■only  a  slight  angular  curvature  little  or  no  alteration  in  the  pelvis  is 
found.  As  regards  situation,  if  the  curvature  is  in  the  dorsal,  especi- 
ally the  upper  dorsal,  region,  a  compensatory  lordosis  develops,  and 
the  pelvis  is  little  affected.  If,  however,  the  curvature  is  situated  in 
the  lower  part  of  the  spinal  column  and  the  lumbar,  and  especially 
the  lumbo-sacral,  region  is  involved,  then  very  decided  deformity  of 
the  pelvis  almost  always  exists. 

The  alteration  in  the  pelvis  (Fig.  100)  consists  in  a  tilting  of  the 
upper  part  of  the  sacrum  backwards,  and  of  the  lower  part  and  the 
coccyx  forwards.  As  a  result  of  this,  the  antero-posterior  diameter  at 
the  brim  is  increased,  and  the  same  diameter  at  the  outlet  diminished. 
The  inclination  of  the  brim  becomes  lessened ;  indeed,  it  may  become 
almost  parallel  to  the  horizon.  The  sacrum  is  often  found  narrow 
and  straightened.  The  transverse  diameter  of  the  pelvis  gradually 
diminishes  from  above  downwards.  At  the  superior  straight  it  is  little 
altered,  but  the  distances  between  the  ischial  spines  and  ischial 
tuberosities  are  decidedly  diminished.  The  striking  feature  of  the 
kyphotic  pelvis  is  a  diminution  of  all  the  diameters  of  the  pelvic  outlet; 
therefore,  one  finds  difficulty  in  labour  when  the  foetal  head  has  reached 
the  lower  part  of  the  cavity. 

It  is  somewhat  curious  that  the  head  should  so  generally  engage  in 
the  oblique  or  transverse  diameter,  for  one  would  expect  that  it  would 
engage  in  the  conjugate,  as  that  is  the  diameter  which  is  increased. 
Another  peculiarity  is  the  frequency  with  which  the  occiput  rotates 


L72 


OPERATIVE  MIDWIFKIIY 


backwards,  Many  writers  have  referred  to  this,  and  Klein's1  in- 1 
vestigations  confirm  those  of  such  writers  as  Spiegelberg  and| 
( Mshausen. 

Until  recently  I  had  seen  very  little  trouble  in  cases  of  kyphotic 
pelvis ;  but  within  the  last  five  years  I  have  had  five  cases  of 
extreme  dystocia  under  my  care.  All  who  have  collected  a  number 
of  cases   have   had    a   similar  experience.     Champneys2   gives    the 


Fig.  100.-  Kyphotic  Pelvis. 


maternal  mortality  us  28  per  cent,  and  the  fu'tal  as  40  per  cent- 
Klein's  figures  for  the  mother  are  much  better,  but  exactly  the  same 
for  the  child.  Allowing  for  the  fact  that  there  is  always  a  tendenc}- 
to  report  the  graver  cases,  it  must  be  admitted  that  the  malformation 
is  serious  when  the  deformity  involves  the  lower  part  of  the  spinal 
column.  One  thing  that  undoubtedly  leads  to  the  unsatisfactory  results 
mentioned  is  the  fact  that,  as  the  difficulty  occurs  late  in  parturition,  the 


Archivf.  Gyn.,  L896,  Bd.  1. 


Trans,  Obstet.  Soc,  vol.  \w..  1888. 


DEFORMITIES  OE  THE  BONY  PELVIS 


IT:1. 


necessity  for  serious  operative  interference  is  only  appreciated  after 
labour  has  been  going  on  for  some  time.  It  is  most  important,  there- 
fore, that  the  size  of  the  pelvic  outlet  should  be  very  carefully  estimated 
during  pregnancy  or  early  in  labour  in  all  cases,  but  especially  in  low 
kyphosis. 

The  index  for  treatment  in  kyphotic  pelvis  is  the  length  of  the  trans- 
verse diameter  of  the  outlet,  the  distance  between  the  tuberosities. 
If  it  is  3  inches  (7'5  centimetres),  delivery  should  not  be  difficult,  but 
below  that  figure  it  becomes  increasingly  difficult,  and  at  2£  inches 
Cesarean  section  or  symphysiotomy  if  the  child  is  living,  and  cranio- 
tomy if  it  is  dead,  is  the  treatment  indicated.  Klein  advocates  sym- 
physiotomy, and  claims  that  a  2-inch  separation  at  the  symphysis 
gives  an  increase  of  fully  1}  inches  between  the  tuberosities.  I  have 
once  performed  pubiotomy  for  this  condition,  and  am  satisfied  that  it 
is  sound  treatment  when  the  deformity  is  decided. 


Fig.  101.— Pelvis  Obteota.     (Fehling). 

Fehling  has  given  the  special  name  '  pelvis  obtecta '  (Fig.  101)  to 
a  form  of  kyphosis  in  which  the  lumbar  vertebrae  overhang  the  brim 
and  prevent  the  child  engaging. 

Besides  the  ordinary  kyphotic  pelvis  already  described,  one  some- 
times encounters  mixed  forms — for  instance,  a  rickety  kyphotic  pelvis. 
If  the  rachitis  has  been  at  all  severe,  the  deformity  follows  more  that 
type ;  if,  however,  it  has  been  slight  and  the  curvature  is  situated 
high,  then  the  one  deformity  may  counteract  the  other.  One  cannot, 
however,  generalize  on  such  variations,  nor  upon  the  treatment. 

Scoliosis. — Lateral  curvature  of  the  spinal  column,  to  any  very 
marked  extent,  is  usually  a  rachitic  manifestation,  and  if  the  scoliosis 
is  of  non-rachitic  origin  it  is  quite  negligible  from  the  obstetric 
standpoint. 

The  scolio-rachitic  pelvis  has  been  already  mentioned  (Fig.  93),  and 
its  importance  as  influencing  the  passage  of  the  head  through  the  brim 
has  been  referred  to.     A  curvature  of  the  spinal  column  high  up  will 


17  1  OPERATIVE  MIDWIFERY 

not  have  the  same  effect  as  one  situated  low  down,  for  a  compensat  >v\ 
scoliosis  occurs  in  the  former.     The  malformation  is  similar  to  that 
Found  in  rickets,  only  the  promontory  is  pushed  over  to  the  affected  side, 
so  that  the  pelvic  brim  is  of  extremely  irregular  outline. 

Spondylolisthesis.  By  this  term  is  meant  a  slipping  down  of  the 
last  lumbar  vertebra  in  front  of  the  promontory  (Fig.  102).  In  slight 
cases  it  only  projects  a  little  way  over  the  promontory,  but  in  extreme 


Fig.  102. — Spondylolisthetic  Pelvis.    (Bamm. 

cases  it  projects  right  down  in  front  of  the  first  sacral  vertebra.  The 
remaining  lumbar  vertebrae  also  sink  down,  and  the  fourth  and  third 
may  actually  project  over  the  superior  straight — not,  however,  to  any- 
thing like  the  same  extent  as  occurs  in  the  '  pelvis  obtecta.' 

It  can  be  readily  understood  that  the  deformity  causes  great 
alteration  in  the  pelvic  capacity.  The  promontory  is  displaced  back- 
wards, but  the  'obstetrical  conjugate,'  the  distance  between  the 
symphysis  and  the  most  projecting  part  of  the  vertebral  column,  is. 


DEFORMITIES  OF  THE  BONY  PELVIS  175 

very  much  lessened.  The  sacrum  being  pushed  backwards  and  the 
lower  lumbar  vertebrae  downwards,  the  superior  straight  becomes 
more  and  more  nearly  parallel  with  the  horizon.  The  pelvic  outlet 
becomes  diminished  antero-posteriorly. 

The  appearance  of  subjects  with  this  deformity  is  quite  character- 
istic ;  the  trunk  seems  to  have  sunk  down  into  the  pelvis,  while  behind 
there  is  often  to  be  seen  the  projecting  spine  of  the  last  lumbar 
vertebra.  The  diagnosis,  therefore,  should  seldom  be  difficult,, 
although  there  are  other  conditions,  such  as  mollities  ossium  and 
a  low  kyphosis,  which  produce  a  shrinking  down  of  the  trunk.  By 
internal  examination  the  projecting  vertebra  will  be  readily  felt. 

The  most  generally  accepted  view  of  the  etiology  of  this  malforma- 
tion is  that  it  results  from  maldevelopment  of  the  interarticular 
processes  of  the  last  lumbar  vertebra.  A  history  of  accidents,  falls, 
etc.,  and  the  carrying  of  heavy  weights,  can  rarely  be  obtained.  The 
frequency  of  the  condition  is  variously  stated.  Lane  considers  it  by 
no  means  uncommon  ;  Olshausen  and  Yeit x  mention  seventy  anato- 
mical recorded  cases,  but  Breus  and  Kolisko  maintain  that  in  the 
various  collections  there  exist  only  some  twenty  genuine  specimens. 
The  reason  for  this  discrepancy  is  probably  that  Lane  includes 
the  slighter  cases  of  projection  of  the  last  lumbar  vertebra,  while  the 
others  only  accept  extreme  cases.  As  has  been  already  stated,  one 
sometimes  finds  the  last  lumbar  vertebra  pushed  forwards  and  down- 
wards in  the  rachitic  pelvis,  and  if  one  were  to  include  such  cases  the 
frequency  would  certainly  be  much  higher  than  even  Olshausen  and 
Yeit  state. 

However,  these  are  matters  of  anatomical  interest.  What  is  of 
real  practical  importance  is  that  the  deformity  is  a  very  serious  one 
indeed.  Only  in  the  very  slight  degrees  of  the  deformity  is  it 
possible  to  deliver  the  child  -per  vias  naturales,  either  by  forceps  or 
symphysiotomy.  Csesarean  section  if  the  child  is  alive  and  craniotomy 
if  it  is  dead  are,  therefore,  the  operations  to  be  considered. 

IV.  Deformities  from  Diseases  of  the  Lower  Extremities. 

The  deformities  resulting  from  disease  of  the  lower  limbs  are  usually 
unilateral.  Coxalgia,  dislocation,  and  shortening  of  the  leg  from  any 
cause,  of  which,  perhaps,  infantile  paralysis  is  the  most  striking,  are 
the  chief  affections  encountered.  The  deformity  resulting  from  each 
of  these  conditions  is  much  the  same,  although  in  coxalgia  it  is  usually 
most  marked. 

In  hip-joint  disease,  if  the  child  is  very  young  and  the  affected  side 

1  '  Lehrbuch,'  1902. 


L76  OPERATIVE  MIDAVIFKKV 

is  partly  arrested  in  its  development,  an  ankylosis  of  sacrum  and  ilium 
may  result.  As  the  child  goes  about,  however,  and  most  of  the  weight 
is  thrown  on  the  sound  leg,  an  oblique  distortion  of  that  side  of  the 
pelvis  follows. 

The  deformity  is  seldom  so  great  as  to  cause  extreme  distortion, 
such  as  would  necessitate  any  of  the  major  operations,  although  on 
one  occasion  I  saw  a  case  of  double  coxitis  where  the  deformity  was  so 
decided  as  to  necessitate  the  induction  of  premature  labour. 

In  the  case  of  congenital  dislocation  of  the  femur,  or  a  dislocation 
occurring  in  early  life,  the  head  of  the  bone  is  displaced  on  to  the 
ilium,  where  a  new  joint  forms.  The  affected  leg  being  shortened,  the 
greater  part  of  the  body-weight  is  borne  by  the  sound  leg,  and  conse- 
quently that  side  of  the  pelvis  is  pushed  in.  In  congenital  dislocation 
of  both  femurs  both  sides  are  pushed  in,  and  so  the  brim  is  narrowed 
transversely.  Similar,  but  less  marked,  deformities  may  follow 
shortening  or  absence  of  a  limb  from  any  cause,  if  it  occurs  in 
-early  life. 


CHAPTER  XII 

DYSTOCIA  THE   RESULT  OF   ABNORMALITIES  AFFECTING  THE 
PARTURIENT  CANAL— Continued 

Diagnosis,  Prognosis,  and  Treatment  of  Pelvic  Deformity,  more 
especially  of  the  Rachitic  Varieties  of  Malformation. 

In  considering  the  rarer  forms  of  pelvic  deformity,  I  briefly  referred  to 
the  diagnosis,  prognosis,  and  treatment  of  the  particular  one  under 
consideration.  With  rachitic  pelvis,  however,  I  did  not  do  so,  for, 
being  the  commonest  variety  of  deformity,  and  the  one  on  which  all 
discussions  of  diagnosis  and  treatment  are  based,  I  felt  it  required  to 
be  treated  in  a  special  chapter.  The  following  remarks,  therefore, 
have  reference  to  the  rachitic  pelvis.  It  will  be  found,  however,  that 
the  methods  of  examination  and  the  principles  which  guide  one  in 
the  choice  of  treatment  apply,  with  certain  alterations  and  reserva- 
tions, to  the  other  deformities.  I  cannot  commend  too  warmly  the 
subject  which  is  now  to  be  considered,  for  I  know  of  no  pathological 
condition  which  calls  for  greater  judgment  than  the  treatment  of 
contracted  pelvis. 

Diagnosis. — A  suspicion  of  pelvic  deformity  is  aroused  by  smallness 
of  a  woman's  stature,  by  a  waddling  gait,  and  by  malformation  of 
her  limbs  or  spine ;  also,  in  the  case  of  a  primipara,  by  a  pendulous 
abdomen  and  by  the  foetal  head  not  being  fixed  at  the  brim  at  the 
commencement  of  labour,  and  in  a  multipara  by  a  history  of  previous 
tedious  and  instrumental  labours.  But  while,  undoubtedly,  these 
features  are  commonly  associated  with  pelvic  deformity,  one  must  not 
attach  too  much  importance  to  their  presence  or  absence.  Cases 
occur  in  which  all  these  peculiarities  are  distinct  and  yet  the  capacity 
of  the  pelvis  is  little  diminished  and  parturition  is  but  little  disturbed  ; 
while,  on  the  other  hand,  many  women  showing  no  external  deformities 
have  a  pelvic  malformation,  and  in  consequence  a  difficult  parturition. 

It  is  highly  desirable,  therefore,  that  all  primigravid.e  be  examined 
during  pregnancy.  This  is  done  with  greatest  advantage  about  the 
thirty-fifth  week,  when  any  operative  treatment  deemed  necessary 
can  be  arranged.     Should  the  patient's  appearance  or  history  suggest, 

177  " 12 


L78 


OPERATIVE   MIJ'WIFKliY 


or  Bhould  tin-  vaginal  examination  indicate,  any  pelvic  deformity,  an 
exact  measurement  of  the  capacity  of  the  pelvis  must  be  made. 

As  regards  the  external  measurements  of  the  pelvis  there  i-  do 
difficulty.  They  are  taken  with  calipers,  and  it  does  not  matter 
in  the  slightest  which  form  is  employed.  The  routine  measure- 
ments taken  are  the  intercristal,  interspinous,  and  external  conjugate 
diameters,  which  measure  respectively  10f,  10,  and  1\  inches  26*8, 
25,  and  18*7  centimetres).     The  exact  terminal  points  of  the  inter- 


Fig.  103. — Measuring  the  Intercristal  Diameter  of  the  Pelvis. 

spinous  diameter  are  easily  defined — viz.,  the  anterior  superior  spinous 
processes.  With  the  intercristal  diameter  it  is  rather  different.  The 
terminal  points  of  that  diameter  are  the  widest  points  on  the  crests. 
But  the  crest  is  a  bony  ridge  of  some  thickness,  and  it  makes  a  con- 
siderable difference  if  one  measures  from  the  outside  or  the  inside  of 
the  ridge.  Personally,  I  always  measure  from  the  middle,  getting  my 
thumb  and  middle  finger  on  the  inside  and  outside  edge  respectively 
of  the  bony  ridge  (Fig.  103). 

The'  external  conjugate,  known  as  Baudelocque's  diameter  (Fig.  104) 


DIAGNOSIS  OF  CONTRACTED  PELVIS  17!) 

— the  distance  between  a  point  immediately  below  the  projecting  spine 
of  the  last  lumbar  vertebra  and  the  symphysis  pubis — is  less  easily 
determined  because  of  the  difficulty  in  marking  off  the  posterior  point. 
In  certain  individuals,  however,  the  difficulty  may  be  got  over  by  taking 
the  superior  angle  of  a  small  rhomboid  found  often  at  the  lower  part 
of  the  vertebral  column,  and  known  as  Michaelis'  rhomboid  (Fig.  105). 
This  latter  point  very  nearly  corresponds  to  the  point  desired.     There 


Fig.  104. — Measuring  the  External  Conjugate,  or  Conjugate  of  Baudelocque. 

is,  however,  no  very  constant  relationship  between  the  external  con- 
jugate and  the  internal  or  true  conjugate  of  the  brim,  although,  on 
an  average,  the  difference  is  about  3  j  inches  (8*7  centimetres).  Pelvic 
deformity  should,  however,  always  be  suspected  if  it  measures  7  inches 
(17*5  centimetres)  or  under.  Lastly,  the  transverse  diameter  of  the 
outlet  (Fig.  106) — the  distance  between  the  ischial  tuberosities — should 
be  taken  in  all  cases  of  kyphotic  or  funnel-shaped  pelvis.  On  an 
average  it  measures  4|  inches  (11  centimetres). 


L80 


OPERATIVE  MIDWIFERY 


From  these  external  measurements  one  can  only  approximately 
estimate  the  formation  of  the  true  pelvis.  If  one  finds  all  the 
diameters  about  equally  diminished,  a  generally  contracted  pelvis  is 
surmised,  while  if  the  external  conjugate  only  is  altered,  a  Hat  pelvi- 
is  suspected.  The  measurements  which  should  bo  taken  in  the  rarer 
forms  of  pelvic  deformity  are  referred  to  in  the  previous  chapter. 

In  order  to  arrive  at  the  exact  internal  measurements  of  the 
pelvis,  endless  devices  and  many  forms  of  pelvimeter  have  been 
suggested.  Without  exception,  these  instruments  have  proved  of 
little  practical  value,  although   many  of   them  have  seemed  from  a 


Fig.  105. — Michaelia'  Rhomboid. 

The  uppermost  angle  marks  the  posterior  limit  of  the  external 

conjugate  diameter. 

theoretical  standpoint  most  ingenious.  One  of  the  best  is  that  of 
Skutsch  (Eigs.  107  and  108),  and  fairly  accurate  measurements  of  both 
the  conjugate  and  transverse  diameters  can  be  obtained  by  means  of  it. 
The  conjugate  diameter  at  the  brim,  or  conjugata  vera,  is  arrived 
at  by  measuring  first  the  distance  between  the  promontory  and  the 
anterior  surface  of  the  symphysis  pubis,  and  then  deducting  from 
that  the  thickness  of  the  symphysis  (Fig.  107).  The  manner  of 
measuring  the  transverse  is  explained  in  Figs.  103a  and  108/'.  But 
even  with  Skutsch's  pelvimeter  one  cannot  reckon  on  absolute  accuracy, 
and  it  is  evident  that  the  results  obtained  are  not  satisfactory,  for 
within  the  last  few  years  new  forms  of  pelvimeter  have  besn  described 


DIAGNOSIS  OF  CONTRACTED  PELVIS 


LSI 


by  Zweifel1  (Fig.  109)  and  Solowig.2  These  latter  are  to  all  intents 
and  purposes  old  forms  revived,  and  with  absolute  certainty  will  go 
the  way  of  all  others.  From  personal  experience  I  believe  Skutsch's 
pelvimeter  is  the  best,  although  I  have  long  ago  given  up  attempting 
to  measure  the  internal  pelvic  capacity  with  instruments. 

Quite  a  new  principle  characterizes  the  ingenious  invention  of 
Neuman  and  Ehrenfest.3  The  principle  involved  in  the  pelvigraph 
is  that  of  parallel  rulers.  One  arm  localizes  the  various  points  within 
the  pelvis,  while  the  other  has  attached  to  it  a  dial.     The  various 


Fig.  106. — Measuring  the  Transverse  Diameter  of  the  Outlet. 


points  are  mapped  out  on  a  piece  of  paper,  and  the  general  pelvic 
formation  in  sagittal  section  is  constructed. 

I  understand  that  it  has  not  come  up  to  expectation.  Certainly  it 
is  far  too  complicated  for  practical  purposes,  and  this  is  the  conclusion 
come  to  b}T  Sonntag.4 

Radiography  has  not  proved  of  practical  value ;  for  although  with 
X  rays  one  can  obtain  an  idea  of  the  general  pelvic  formation,  so 
far  it  has  been  impossible  to  make  exact  measurements  of  the  pelvic 
diameters. 

i  Zeit.  f.  Gyn.,  1906,  p.  763.  -'  Ibid.,  1905,  No.  24. 

3  Monat.f.  Geb.  u.  Gyn.,  vol.  xi.,  p.  237. 

4  Winckel,  '  Lehrbuch,'  Bd.  ii.,  Teil  ii.,  1905,  p.  1858. 


L82 


<>l'i:i;\TlYK  MIDWIFERY 


FlG.  107. — .Measuring  the  Conjugata  Vera  with  Skutsch's  Pelvimeter. 

First  the  distance  between  the  promontory  and  the  anterior  surface  of  the  symphysis 
pubis  is  taken,  and  then  the  distance  between  the  posterior  and  anterior  surface — 
viz.,  the  thickness  of  the  symphysis.  The  difference  between  these  two  measure- 
ments is  naturally  the  true  conjugate. 


FlG.  108«. — Pelvimetry  with  Skutsch's  Instrument:  tine  Transverse  Diameter  of  Brim. 

Measuring  the  distance  between  the  great  trochanter  and  the  nearest  point  <>f  the 
pelvic  brim  of  the  same  side. 


DIAGNOSIS  OF  CONTRACTED  PELVIS 


Is:  i 


Owing,  therefore,  to  the  unsatisfactory  results  obtained  by  pelvi- 
meters, most  obstetricians  estimate  the  size  of  the  pelvis  manually. 
It  need  hardly  be  said  that  by  such  a  method  accuracy  is  also 
impossible.  No  doubt  the  skilled  obstetrician,  who  has  had  an 
extensive  experience  of  deformed  pelves,  can  estimate  fairly  cor- 
rectly the  pelvic  capacity  by  means  of  his  hand,  and  certainly  the 
chances  which  the  foetal  head  has  of  passing  through,  but  he  cannot 


Fig.   1086. — Pelvimetry  with  Skutsch's  Instrument  :  the  Transverse  Diameter  of  Brim. 

Measuring  the  distance  between  the  great  trochanter  and  the  most  distant  point  of 
the  pelvic  brim  of  the  other  side.  The  difference  between  the  measurements  made 
after  this  and  the  previoxis  figures  is  naturally  the  transverse  diameter  of  the  pelvic 
brim. 


tell  the  student,  for  example,  nor  can  he  put  down  on  paper  its  exact 
measurements. 

The  manual  method  most  generally  employed  in  practice  is  the 
taking  of  the  oblique  conjugate  by  means  of  the  lingers  (Fig.  110), 
and  from  that  measurement  calculating  the  conjugata  vera.  To  do 
this  the  middle  and  forefinger  of  the  right  hand  are  passed  into  the 
vagina  until  the  middle  finger  impinges  on  the  promontory  and  the 
forefinger  is  pressed  against  the  subpubic  ligament.  The  forefinger 
of  the  other  hand  marks  off  the  lower  margin  of  the  subpubic  ligament. 
Both  hands  are  then  withdrawn,  and  the  distance  between  the  tip  oi 


1H-1 


OPERATIVE  MIDWIFERY 


the  niidclle  linger  and  point  marked  on  the  forefinger  measured  with  a 
tape  or  calipers.    In  taking  this  measurement,  it  is  hardly  necessary 

to  say  that  it  should  be  done  with  the  greatest  care,     it  is   D 
important  that  the  linger  be  pressed  against  the  true  promontory  ,  and 
not  against  a  false  one.  and  also  that  the  lower  margin  of  the  Bubpubic 
ligament  be  marked  off  exactly. 

But  here,  again,  conies  a  difficulty,  for  the  difference  between  the 
oblique  and  true  conjugate  is  most  variable.  AVe  commonly  reckon 
the  true  conjugate  as  between  \  and  |  inch  (1*2  and  1*9  centimetres) 
less  than  the  oblique.  But  from  measurements  made  post  mortem  on 
women  whose  pelves  were  examined  during  life  I  have  frequently  found 
this  estimate  of  the  conjugata  vera  entirely  wrong — I  have  found  it  as 
far  wrong  as   'i  inch    (2  centimetres).     The  recent  investigations  of 


Fig.  109. — Zweilel's  Pelvimeter. 


Sellheim1  in  this  connexion  are  of  great  interest.  He  found  that  the 
difference  between  diagonal  and  true  conjugate  varied  from  0  to  8  centi- 
metres (0  to  1/2  inches).  The  older  investigations  of  Skutsch  were 
much  the  same — 0'5  centimetre  to  2*9  centimetres  (0*2  to  1  inch). 

For  practical  purposes,  in  estimating  the  true  conjugate  from  the 
oblique,  one  must  consider — 

1.  The  height  of   the   pubic  symphysis.      The  higher  it  is,    the 
more  must  be  allowed. 

2.  The  height  of  the  promontory.     The  higher  it  is,  the  more 
must  be  allowed. 

3.  The  angle  of  the  pubic  symphysis  to  the  horizon.     The  more 
obtuse  it  is,  the  more  must  be  allowed. 

Other  methods  of  employing  the  fingers  for  measuring  the  pelvis 
Piamsbotham's  method  (Fig.  Ill)  is  quite  im- 


liave  been  suggested. 


1  Zent.f.  (1 !/».,  1904.  p.  :!4'.>. 


DIAGNOSIS  OF  CONTRACTED  PELVIS 


185 


practicable.    The  passing  of  the  whole  hand  into  the  vagina,  however, 
and  employing  the  closed  fist  or  fingers,  as  is  indicated  in  the  illustra- 


Fig.  110.— Measuring  the  Oblique  or  Diagonal  Conjugate. 

tion  (Fig.  112),  gives  the  skilled  accoucheur  a  very  good  idea  indeed 
of  the  general  formation  of  the  true  pelvis,  and  I  frequently  make 


L86 


OPERATIVE  MIDWH'KUY 


use  of  the  method.  It  can  always  be  employed  with  success  both  in 
primipara  and  multipara;  during  labour,  but  only  with  difliculty  and 
under  anesthesia  in  primigravidffl. 

After  delivery,  when  the  abdominal  wall  is  lax  and  the  uterus  can 
be  pushed  aside  or  has  sunk  down  into  the  pelvis,  the  conjugata  vera 
may  be  estimated  externally  by  marking  off  with  the  fingers  the 
distance  between  the  internal  surface  of  the  symphysis  pubis  and  the 


FlG.  111. — Ramsbotham's  Method  of  measuring  the  Conjugata  Vera. 


projecting  promontory.  Sometimes,  even,  by  a  similar  manoeuvre,  it 
can  be  estimated  before  delivery  by  pulling  up  the  uterus ;  but  this  is 
only  possible  in  multipara?  with  lax  abdominal  walls,  and,  as  a  rule, 
only  up  to  the  thirty-second  week.  Ahlfeld,  a  few  years  ago,  showed 
me  wooden  bars  of  various  sizes  which  he  employed  for  estimating 
the  true  conjugate  externally.  Calipers  have  also  been  used.  All 
these  devices  are  employed  in  the  same  way — one  end  of  the  bar 


DIAGNOSIS  OF  CONTRACTED  PELVIS 


1H7 


or  calipers  is  pressed  against;  the  promontory  and  the  other  against 
the  symphysis. 

It  is  perfectly  evident,  therefore,  that  neither  by  the  hands  nor  by 
pelvimeters  can  one  make  an  accurate  measurement  of  the  internal 
capacity  of  the  pelvis,  although  with  practice  a  fairly  good  idea,  correct 
to  about  \  inch  (0"6  centimetre),  may  be  obtained.  Generally  such 
approximate  accuracy  is  all  that  is  necessary,  but  sometimes  it  is  not 
so,  as  I  shall  have  to  point  out  later. 

But  in  contracted  pelvis  there  is  another  very  important  factor 
influencing  the  parturition — viz.,  the  size  of  the  fcetal  head.  The 
fcetal  head  varies  very  much  in  size,  but,  what  is  perhaps  of  even 


Fir;.  112. — Johnson's  Method  of  measuring  the  Conjugata  Vera. 

greater  importance,  it  varies  very  much  in  consistency.  It  is  at 
once  evident  that  a  large  or  much  ossified  head  will  pass  through 
a  contracted  pelvis  less  easily  than  a  small  and  defectively  ossified 
one.  Attempts  have  been  made  to  measure  the  fcetal  head  in  utero 
(Fig.  113),  but  they  have  not  proved  very  successful,  while  con- 
sistency is  impossible  to  estimate  until  labour  has  advanced  some 
way,  for  only  then  can  the  fontanelles  and  sutures  be  felt.  Stone1 
has  claimed  great  accuracy  for  his  method,  which  consists  in 
employing  calipers  applied  to  the  head,  whose  position  and  attitude 
has  been  carefully  palpated. 

We  have,  therefore,  in  practice  to  deal  with  a  canal,  the  pelvis,  and 
a  hod;/  ivhich  has  to  pass  through  that  canal,  the  fcetal  head,  neither 

1  Med.  Bee,  November  4,  1905. 


188 


OPERATIVE  MIDWIFERY 


of  which  can  be  accurately  gauged  as  regards  size.  This  has  been 
recently  appreciated  by  Midler,  Pinard,  and  a  few  others,  who  hav< 
advocated  thai,  after  the  pelvis  is  carefully  measured,  the  relative  Bize 
of  the  head  and  pelvis  should  be  tested.  Barbour  stated  this  very 
succinctly  when  he  said,  '  The  foetal  head  is  the  best  pelvimeter.' 

There  is  here  represented  (Fig.  114)  my  method  for  estimating  the 
relative  size  of  head  and  pelvis.  It  is  for  the  most  part  a  combination  of 
Mailer's  and  Pinard's  methods  slightly  modified,  and  I  believe  improved. 
It  is  a  bimanual  method — the  external  hand  pushes  the  head  into 
the  pelvis,  while  the  internal  fingers  of  the  other  estimate  the  relative 
size  of  pelvis  and  head.     It  may  be  employed  with  or  without  ana  s- 


FlG.  113.— Cephalometer.     (Ferret.) 

thesia,  but  greater  accuracy  is  obtained  if  the  woman  is  anaesthetized. 
The  patient  is  placed  in  the  ordinary  position  for  a  gynaecological 
examination,  and  the  accoucheur  stands  at  her  side,  facing  her.  The 
right  hand  seizes  the  head,  and  presses  it  into  the  superior  straight. 
Two  fingers  of  the  left  hand  are  passed  into  the  vagina.  These 
measure  the  consistency  and  manner  of  engagement  of  the  head  ; 
also,  if  it  has  not  been  done  already,  the  nature  and  extent  of  the 
pelvic  deformity.  Further  information,  however,  is  obtained  by 
utilizing  the  thumb,  which  is  passed  along  the  brim,  and  estimates 
the  degree  of  overlapping.  By  this  method  I  find  the  relative 
size  of  the  foetal  head  and  maternal  pelvis  can  be  very  exactly 
estimated.     There  is  onlv  one  detail  which  has  to  be  watched — viz., 


TEEATMENT  OF  CONTRACTED  PELVIS 


189 


the  variety  of  parietal  obliquity  or  asynclitism,  which  exists,  or  is 
produced  by  the  external  hand. 

To  sum  up,  then,  the  manner  in  which  one  should  approach 
a  case  of  contracted  pelvis  is  as  follows :  (1)  The  general  appear- 
ance of  the  patient  and  the  obstetric  history,  if  she  is  a  multipara,, 
is  noted.  (2)  The  external  and  internal  pelvic  capacity  is  carefully 
measured.  (3)  Finally,  the  relative  size  of  the  foetal  head  and  the 
maternal  pelvis  is  estimated.  Having  done  all  this — but  not  until 
then — one  is  in  a  position  to  consider  the  treatment. 


Fig.  114.— Author's  Method  for  estimating  Relative  Size  of  Pcetal  Head  and 
Maternal  Pelvis. 

Prognosis  and  Treatment. 

Everyone  is  aware  that  deformity  of  the  pelvis,  except  it  be  of 
a  slight  degree,  is  a  dangerous  condition  for  mother  and  child.  To 
give  figures  which  would  represent  exactly  how  dangerous  is  quite 
impossible,  for  so  much  depends  upon  the  extent  of  the  deformity  and 
the  treatment  adopted.  Many  times,  too,  the  mother's  and  child's 
interests  are  directly  opposed  to  one  another,  for  the  more  the  mother's 
life  is  considered,  the  greater  is  the  child's  endangered,  and  vice  versa. 
Take  induction  of  labour  and  Cesarean  section.  In  the  former  the 
foetal  mortality  is  enormous,  but  the  maternal  almost  negligible ;  in 
the  latter  the  maternal  is  still  considerable,  but  the  foetal  is  small. 


190  OPERATIVE  MIDWIFERY 

It  is  not  possible  to  consider  here  all  the  details  of  the  treat- 
ment of  contracted  pelvis.  These  details  will  be  found  discussed 
elsewhere,  chiefly  in   connexion   with   the   various   operations.     My 

purpose  at  present  is  to  treat  the  subject  generally,  and  to  point 
out  the  principles  which  should  guide  one  in  approaching  a  case 
of  contracted  pelvis  and  in  coming  to  a  decision  regarding  treat- 
ment. 

Many  students  and  practitioners  think — and  they  are  encour 
to  do  so  by  the  general  teaching  in  all  but  a  few  of  the  modern  text- 
books— that  the  treatment  to  be  adopted  in  cases  of  contracted  pelvis 
should  be  based  upon  the  size  of  the  conjugate  diameter  of  the  brim 
of  the  pelvis. 

No  exception  can  be  taken  to  such  an  attitude  towards  major  and 
minor  deformities,  but  it  is  an  absolutely  erroneous  one  to  assume 
towards  medium  degrees  of  pelvic  deformity,  the  class  of  deformity 
which  is  by  far  the  most  common. 

But,  first  of  all,  let  me  define  these  different  degrees. 
By  minor   pelvic   deformity   I   mean   a   conjugata   vera   of   over 
3f  inches  (9'3  centimetres),  by  major  deformity  where  it  is  below 
3  inches   (7*5   centimetres),  and   by   medium   deformity  where   it   is 
between  3|  and  3  inches. 

In  major  and  minor  deformities  the  size  of  the  pelvis  alone 
determines  the  treatment,  for  in  the  latter  spontaneous  delivery  or 
forceps  always  results  in  a  satisfactory  termination,  while  in  the 
former,  the  major  degrees  of  pelvic  deformity,  Cesarean  section  and 
craniotomy  are  practically  the  only  alternatives. 

With  medium  degrees  of  pelvic  deformity,  however — that  is  to  say, 
the  deformities  where  the  conjugate  is  from  3f  to  3  inches  (9'3  to 
7 '5  centimetres) — it  is  quite  otherwise,  for  in  such  cases  there  are 
several  alternative  treatments  which  have  to  be  considered  if  the 
child  is  living.  They  are,  leaving  the  case  to  Nature,  version,  forceps, 
induction  of  premature  labour,  symphysiotomy,  and  Cesarean  section. 
No  hard-and-fast  lines  can  be  laid  down  for  cases  of  this  group. 
Experience  alone  can  teach  one  how  to  deal  with  these  cases,  which, 
more  than  all  others,  tax  the  obstetrician's  skill  and  judgment.  This 
I  would  say,  however — it  is  absolutely  essential  to  base  the  treatment 
upon  the  relative  size  of  the  foetal  head  and  tin  maternal  pelvis,  for 
in  cases  in  which  by  pelvimetry  the  pelves  ore  tin-  same  sometimes  one 
operation,  sometimes  another,  will  be  found  best. 

From  11)01  to  190<>  inclusive,  1  had  under  my  care  in  the 
Glasgow  Maternity  Hospital  and  private  practice  230  cases  in 
which  the  conjugata  vera  was  3.1  inches  (8*7  centimetres)  and 
under.     Cases  in  which  it  was  more  than  that  figure  are  not  included. 


TREATMENT  OE  CONTRACTED  PELVIS 


UN 


In  these  cases  the  following  are  the  results  as  regards  mothers  and 
children : 

Author's  Cases  of  Contracted  Pelvis  3^  Inches  (8*7  Centimetres) 
and  Under  (1901-190G). 


Operation. 

Total  Cases. 

Maternal 
Mortality. 

Immediate  and 
Late  Fcjetal 
mortality.  > 

Per  Cent. 

0 
30 

37 
100 
0 
1-8 

Spontaneous  delivery 
Forceps     ... 
Induction  of  labour 
Craniotomy 
Symphysiotomy 
Caesarean  section     ... 

7 
76 
23 
63 

8 
53 

Per  Cent. 
0 

1-4 
0 
12-6 

o 

9-4 

Spontaneous  Delivery. — Naturally,  up  to  a  certain  point,  spon- 
taneous delivery  gives  the  best  results  for  mother  and  child.  From  that 
point,  however,  the  prognosis  becomes  less  favourable.  The  point,  so 
far  as  I  can  judge,  is  3 -J-  inches  (8*7  centimetres)  for  flat  and  3|  inches 
(9*3  centimetres)  for  generally  contracted  pelvis.  During  the  last  six 
years  in  the  Glasgow  Maternity  Hospital  we  have  had  quite  a  number 
of  women  delivering  themselves  spontaneously  whose  pelves  were  of 
the  size  I  mention ;  but  only  once  or  twice  has  a  full-time  child  been 
driven  through  a  pelvis  of  3  inches  (7"5  centimetres).  In  the  Queen 
Charlotte  Hospital  Report  for  1905  a  case  is  recorded  of  a  primipara 
who  delivered  herself  of  a  child  weighing  5  pounds  12f  ounces  in  ten 
hours,  although  she  had  a  flat  rachitic  pelvis  in  which  the  C.Y.  was 
only  2-f  inches  (7*1  centimetres).     Peham'2  mentions  two  cases. 

Here  is  an  interesting  table  made  up  by  Kronig  for  the  Leipzig 
Klinik  of  Zweifel : 


Generally  Contracted 

Pelvis. 

Flat  Pelvis. 

C.Y. 
(4 

10-9  cm. 
'SI"). 

C.V.8-9-7-5cm. 

(:ii"-3"). 

C.V.  7-4  cm. 

and  under 

(3"  and  under). 

C.V.  9 

(31 

5-S'5cm. 
'-3|"). 

C.V.  S-4-7  cm. 
(3|"-2|"). 

C.V.  6*9  cm. 

and  under  (2| " 

and  under). 

<D 

m 

a 

"o 
EH 

Spon- 
taneous 
or  Little 
Help  at 
Outlet. 

S     1   Spon- 

§      taneous 
°     'or  Little 
3      Help  at 
o     '  Outlet. 

0 

H 

Little 
Help  at 
Outlet. 

6 

Is 
o 
H 

Little 
Help  at 
Outlet. 

Total  Cases. 

Little 
Help  at 
Outlet. 

j 
i         Little 
°       Help  at 
3       Outlet. 

Primipara 
Multipara 

48 
SS 

45 
84 

43           35 
57           39 

8 
10 

none 
none 

127 
22S 

120 
209 

30 

S4 

28 
46 

S         none 
7         none 

1  By  '  immediate '  mortality  is  meant  that  the  children  are  born  dead,  and  by 
'late'  mortality  that  the  children  have  died  while  the  mothers  have  been  in 
hospital  or  under  supervision  in  their  homes. 

-  '  Das  enge  Beckcn,'  1908. 


L92  OPERATIVE  MIDWIFERY 

From  these  figures  it  is  perfectly  evident  that  the  possibility 
of  spontaneous  delivery  through  a  narrow  brim  is  greater  than  is 
generally  supposed,  and  as  my  experience  increases  I  am  more  and 
more  convinced  of  this ;  but  I  find  it  very  difficult  to  persuade  others 
of  the  fact.  They  become  impatient  and  uneasy  about  the  woman's 
sufferings,  and  think  they  should  interfere.  It  is  certainly  distressing 
to  see  a  woman  suffering,  but  anxiety  regarding  the  child  is  unneces- 
sary. I  frequently  observe  spontaneous  delivery  through  pelves  of 
:>\  inches  (8*7  centimetres)  where  the  second  stage  lasts  live,  seven, 
even  twelve  hours,  yet  the  children  are  living,  and  the  mothers  are 
none  the  worse.  It  is  hardly  necessary  to  repeat  here  that  in  all 
cases  of  prolonged  labour  the  condition  of  both  mother  and  foetus 
must  be  carefully  watched. 

But  another  great  advantage  of  spontaneous  delivery  is  the  low 
fcetal  mortality.  Boenninghausen  gives  the  foetal  mortality  for  spon- 
taneous delivery  in  generally  contracted  pelvis  as  2-2  per  cent.,  and 
for  fiat  rachitic  pelvis  27  per  cent.,  while  in  artificially  terminated 
labours  the  mortality  was  41  per  cent,  and  47  per  cent.,  according 
as  the  pelvis  was  generally  contracted  or  flat.  Peham1  gives  the 
mortality  as  3  per  cent. 

In  none  of  my  recent  cases  has  there  been  a  fcetal  death.  Equally 
good  results  will  be  found  in  the  recent  reports  of  Queen  Charlotte 
Hospital,  London,  and  the  Rotunda  Hospital,  Dublin.  One  naturally 
expects  a  much  higher  total  mortality  where  operative  interference  is 
had  recourse  to ;  but  few,  I  feel  convinced,  are  aware  of  how  small  the 
ftetal  mortality  is  in  suitable  cases  left  to  Nature. 

In  medium  degrees  of  pelvic  deformity  the  following  factors 
influence  the  passage  of  the  head  through  the  pelvis :  (a)  The  extent 
and  nature  of  the  deformity ;  (/;)  the  size  and  consistency  of  the 
head;  (<■)  the  variety  of  biparietal  obliquity  present;  (d)  the  posi- 
tion of  the  occiput ;  (<•)  the  strength  of  the  expulsive  forces.  I  have 
already  said  sufficient  regarding  the  degree  of  deformity.  Without 
doubt  it  is  the  most  important  factor,  although  the  two  following 
have  more  influence  than  is  generally  admitted. 

It  is  perfectly  obvious  that  the  size  and  consistency  of  the  head, 
being  a  very  variable  quantity,  must  be  a  factor  of  considerable 
importance,  especially  in  cases  where  the  deformity  is  on  the  border- 
line of  being  too  much  for  the  forces  to  overcome.  Probably  con- 
sistency is  even  more  important  than  size,  unless  the  latter  is  extreme. 
Personally,  I  have  found  the  average  weight  and  size  of  head  of  the 
children  born  of  rachitic  parents  slightly  higher  than  that  of  ordinary 

1  '  Das  enge  Becken,'  1908. 


TREATMENT  OF  CONTEACTED  PELVIS  193 

children.  Pinard1  has  remarked  upon  this  also.  The  subject  is  fully 
discussed  by  Wilcke.2 

Of  very  great  importance  indeed  in  flat  pelvis  is  the  next  factor,  the 
variety  of  biparietal  obliquity  present.  The  posterior  parietal  presenta- 
tion is  extremely  unfavourable  both  as  regards  spontaneous  and  forceps 
deliveries.  It  is  quite  unnecessary  to  mention  other  writers  in  support 
of  this  view,  for  all  are  agreed  that  the  posterior  parietal  presentation 
is  infinitely  less  favourable  than  the  anterior.  One  need  not  consider 
the  subject  again — -it  is  fully  discussed  in  the  previous  chapter. 

In  cases  of  scolio-rachitic  pelvis — a  variety  of  rachitic  deformity 
which  I  have  found  not  uncommon — the  position  of  the  occiput  may 
influence  the  passage  of  the  head  through  the  brim,  for  it  is  at  once 
apparent  that  the  head  will  pass  more  readily  if  the  occiput  is 
directed  towards  the  more  roomy  side. 

As  regards  the  expulsive  forces,  the  last  important  factor  in- 
fluencing the  labour,  little  need  be  said.  Naturally,  the  stronger 
they  are,  the  greater  is  the  probability  of  the  labour  terminating 
spontaneously.  In  flat  pelvis  one  usually  finds  them  quite  up  to,  and 
often  even  above,  the  normal,  but  in  generally  contracted  pelvis  of  the 
non-rachitic  variety  they  are  not  infrequently  rather  feeble.  This  has 
been  already  referred  to  in  speaking  of  the  expulsive  forces  as  a  cause 
of  delay  in  labour. 

Turning  now  to  the  artificial  methods  of  delivery  in  contracted 
pelvis,  version  and  forceps  are  the  only  two  I  intend  considering 
at  present.  The  results  from  the  other  operations,  induction  of  labour, 
symphysiotomy,  craniotomy,  and  Csesarean  section,  will  be  considered 
in  separate  chapters.  For  the  sake  of  continuity,  however,  I  would 
say,  in  regard  to  symphysiotomy  or  pubiotomy,  that  my  present 
attitude  towards  it  is  to  employ  it  only  in  cases  where,  after  two 
attempts  with  forceps,  I  fail  to  extract  the  child — where,  in  other  words,  I 
feel  that  a  little  more  room  in  the  pelvis  is  all  that  is  necessaiw  to  permit 
of  delivery  per  vias  naturales.  As  regards  induction  of  labour,  my 
results  have  been  so  unsatisfactory  that  at  present  I  perform  this 
operation  very  seldom. 

Version. — Podalic  version,  early  or  late,  was  abandoned  by  us  in  the 
Glasgow  Maternity  Hospital  some  years  ago,  because  we  found  the  results 
to  both  mother  and  child  were  less  satisfactory  than  when  forceps  was 
employed.  So  much  was  I  impressed  with  the  unsatisfactory  results 
from  podalic  version  that  in  presentations  of  the  breech  it  has  been 
my  practice  during  the  last  few  years  to  perform  external  cephalic 
version  during  pregnancy  whenever  that  was  possible,  and  the  pelvis 

i  Ann.  de  Gyn.,  1898,  p.  81. 

2  Hegar,  Beitr.  Gel.  u.  Gyn.,  1901,  Bd.  iv.,  p.  291. 

13 


l'.u  OPERATIVE  MH>\\ll'i:i;Y 

waa  only  moderately  deformed.  Such  a  procedure  has  this  great 
advantage,  that  it  permits  the  accoucheur  testing  the  relative  size  of 
head  and  pelvis,  so  important  a  guide  to  treatment,  and  which  other- 
wise he  could  not  do  if  the  presentation  remained  pelvic. 

The  arguments  advanced  in  favour  of  version  as  against  forceps  in 
flat  pelvis  are  familiar.  The  most  important  are  that  the  wedge- 
shaped  head  passes  through  more  easily  base  first ;  that  the  parietal 
bones  overlap  better  with  the  after-coming  than  with  the  fore- 
coming  head  ;  and  that,  as  forceps  must  compress  the  head  in  the 
longitudinal  diameter,  it  produces  a  compensatory  increase  in  the 
biparietal  diameter — the  fcetal  diameter  which  is  engaging  in  the 
narrowest  diameter  of  the  pelvis,  and  which,  in  consequence,  one 
wishes  to  remain  as  small  as  possible.  Simpson  usually  gets  the  credit 
for  having  advanced  the  first  of  these  three  arguments  in  favour 
of  version,  although  long  before  his  time  it  was  appreciated  and  taught. 

The  last  argument,  however,  was  the  one  to  which  most  weight 
was  attached  until  Budin  and  Milne  Murray  disproved  the  truth  of 
the  statement. 

Long  ago  Baudelocque1  proved  by  experiment  that  longitudinal 
compression  of  the  head  did  not  produce  a  compensatory  increase  of 
the  biparietal  diameter ;  but  he  left  the  matter  there,  and  his  experi- 
ments were  forgotten  until  Budin,  and  later  Milne  Murray,'-  repeated 
them.  These  latter  observers  found  that  Baudelocque  was  correct  in 
his  observations,  but  they  went  a  step  farther,  and  found  in  their 
experiments  that  the  compensatory  increase  occurred  in  the  vertical 
diameter  of  the  head,  a  measurement  Baudelocque  neglected  to  take. 
I  have  repeated  the  experiments  of  Budin  and  Murray,  and  have 
obtained  similar  results. 

Neither  from  practical  experience  nor  on  theoretical  grounds, 
therefore,  is  version  better  than  forceps,  and  this  is  the  opinion  of 
British  obstetricians.  Several  obstetricians  in  France,  (lermany,  Italy, 
and  America  still  favour  prophylactic  version.  There  is,  however, 
not  the  same  enthusiasm  about  the  treatment  now  as  formerly, 
and  even  those  who  approve  of  it  only  do  so  for  the  slighter  forms 
of  contracted  pelvis.  But  having  condemned  version  in  general  in 
rlat  pelvis,  I  will  make  three  exceptions — viz.,  cases  of  posterior 
parietal  presentation,  cases  in  which  in  scolio-rachitic  pelvis  the 
occiput  is  directed  to  the  narrow  side,  and  cases  in  which  other 
complications  requiring  version,  such  as  placenta  prsevia,  coexist.  It 
is  quite  evident  from  what  has  been  said  why  these  exceptions  should 
be  admitted. 

1  'A  Svstem  of  Midwifery.'  translated  by  Heath.  17VIU,  vol.  ii..  p.  "-77. 

2  Eilin.  Med.  Joum.,  lyss.  vol.  xxxiv.,  p.  417. 


TREATMENT  OF  CONTRACTED  PELVIS  195 

I  have  said  that  for  many  years  the  British  school,  in  general, 
have  been  opposed  to  version.  It  is  no  small  satisfaction,  therefore, 
to  find  evidence  that  other  schools  are  coming  to  a  like  opinion, 
but,  be  it  noted,  they  are  not  coming  to  our  opinion,  because  they 
favour  forceps.  Don't  for  a  moment  let  us  imagine  that  is  the  reason. 
They  are  opposed  to  version,  because  spontaneous  delivery  occurs  more 
often  than  was  supposed.  Kronig  writes  as  follows:1  'Version  on 
account  of  contracted  pelvis,  the  so-called  prophylactic  version,  cannot 
be  recommended,  for  the  prognosis  for  mother  and  child  is  less 
favourable  than  birth  of  the  child  by  a  head  presentation.'  Baisch2 
gives  the  results  for  the  Tubingen  Klinik,  and  his  opinion  regarding 
version  is  the  same.  In  France  neither  forceps  nor  version  is  favoured 
by  Pinard  and  his  many  followers.  They  hold  that  if  spontaneous 
delivery  does  not  occur,  symphysiotomy  should  be  had  recourse  to. 
The  theory  is  quite  logical — indeed,  like  so  many  other  views  of  this 
great  obstetrician,  it  is  too  logical.  It  appears  to  me  too  extreme,  for 
there  must  be  some  cases  in  which  the  head  requires  just  a  little  help 
through  the  brim,  and  surely  this  may  be  safely  given  with  forceps. 
There  is,  however,  another  school  in  France  which  still  favours  version. 

Forceps. — Turning  now  to  forceps,  it  is  apparent  from  my  table 
(p.  191)  that  the  foetal  mortality  with  it  is  very  high — 30  per  cent.  It 
must  not  be  forgotten,  however,  that  I  only  include  pelvic  deformity 
when  the  vera  is  3^  inches  and  under  (8*7  to  7*5  centimetres),  and  that 
I  include  both  the  early  and  late  mortality.  But  even  allowing  for 
that,  the  foetal  mortality  is  greater  than  it  should  be.  In  recent  years, 
however,  I  have  improved  this  by  giving  the  head  a  much  longer  time 
to  mould.     In  1909  I  had  no  foetal  death  in  my  clinic.3 

As  with  spontaneous  delivery,  so  with  forceps,  the  results  up  to 
a  certain  point  are  quite  satisfactory,  the  turning-point  seeming  to  be 
3\  inches.  With  a  vera  down  to  and  including  3^  inches  (8*7  centi- 
metres) the  foetal  mortality  is  10  per  cent.,  with  a  vera  of  3|  inches 
(8*1  centimetres)  25  per  cent.,  with  a  vera  of  3  inches  (7"5  centimetres) 
40  per  cent.  But  apart  from  the  foetal  mortality,  there  is  the  foetal 
morbidity  to  be  considered.  Whenever  one  passes  below  3i  inches 
the  foetal  morbidity  becomes  greatly  increased — in  my  cases  by  as  much 
as  four  times.  Indeed,  indentation,  severe  bruising,  and  deep  asphyxia, 
become  comparatively  common.  It  appears  to  me,  therefore,  that 
forceps  should  only  be  employed  in  exceptional  eases  when  the  cohjugata 
vera  is  below  3i-  inches  (8'7  centimetres),  and  seldom,  if  ever,  when  it  is 
under  3]  incites,  and  that  the  instrument  should  be  had  recourse  to  only 

1  Op.  cit.,  p.  100.  2  Monat.f.  Geb.  u.  Gyn.,  1905,  vol.  xx.,  p.  174. 

3  'Clinical  Report,'  by  Dr.  David  Shannon,  Glasgow  Medical  Journal. 
March,  1910. 


196  OPERATIVE  MIDWIFERY 

when  the  head  is  well  fixed  at  the  brim  and  does  not  overlap,  and  only 
after  considerable  time  has  been  given  the  head  to  mould,  Finally,  that 
only  very  moderate  traction  should  be  employed. 

The  same  factors  influence  forceps  delivery  as  we  have  seen  in- 
fluence spontaneous  delivery.  Posterior  parietal  presentations  are 
extremely  unfavourable. 

With  few  exceptions,  obstetricians  outside  of  Britain  are  opposed 
to  the  employment  of  forceps  to  pull  the  head  past  the  obstruc- 
tion. They  only  countenance  forceps  after  the  greatest  circum- 
ference of  the  head  has  passed  the  contraction.  This  is  becoming 
the  teaching  also  of  a  few  in  this  country.  With  such  a  united 
opinion  against  the  operation,  it  is  at  once  evident  that  forceps,  if 
employed  at  all,  must  be  used  with  great  caution.  The  promiscuous 
employment  of  the  instrument  for  pulling  the  head  through  the  brim 
and  the  use  of  brute  force — a  practice  so  common  in  this  country — 
cannot  be  too  strongly  condemned.  It  is  simply  deplorable  to  see 
cases  brought  into  hospital  where  for  hours  the  medical  attendant 
and  his  confreres  have  been  making  attempts  to  deliver  with  forceps, 
when  such  an  operation  should  never  have  been  contemplated. 

But  having  said  so  much  against  the  employment  of  ill-advised 
force  and  the  dragging  of  the  child  past  an  obstruction,  the  one  extreme, 
I  am  not  prepared  to  go  to  the  other  extreme  and  say  that  forceps 
should  only  be  employed  after  the  greatest  circumference  of  the  fcetal 
head  has  passed  the  obstruction,  and  never  to  help  it  past  the  obstruc- 
tion. Personally,  I  still  practise  and  teach  that  in  carefully  selected 
cases  forceps  may  be  employed  with  most  satisfactory  results,  even 
although  the  greatest  circumference  of  the  head  has  not  passed  the 
brim ;  but  the  head  must  be  fixed,  and  there  must  not  be  any 
appreciable  overlapping  at  the  brim.  Besides,  only  one  or  two 
attempts  with  moderate  force  are  to  be  made.  If  they  fail,  then  some 
other  treatment  must  be  employed.  For  such  cases  axis-traction 
forceps  is  peculiarly  suitable,  and  is  much  better  than  the  ordinary 
double-curved  instrument.  It  must  not  be  forgotten,  also,  that  in  flat 
pelvis  the  Walcher  position  is  often  of  great  assistance.  This  subject, 
however,  is  referred  to  under  Forceps  Delivery  in  Contracted  Pelvis 
(Chapter  XXIV.). 

So  far  I  have  discussed  the  use  of  forceps  from  the  standpoint  of  j 
the  child — at  least,  the  figures  given  had  reference  to  foetal  mortality 
and  morbidity.  I  have  done  this  purposely,  because  the  maternal 
morbidity  and  mortality  should,  theoretically,  be  nil.  As  far  as 
mortality  goes,  this  is  nearly  the  case.  In  my  list  there  is  one  death, 
but  the  patient  had  been  handled  for  long  by  a  midwife  before  she 
was  admitted  to  hospital.     But  what  about  morbidity  ?     Amongst  the 


TREATMENT  OF  CONTRACTED  PELVIS  11)7 

cases  of  contracted  pelvis  which  have  been  delivered  by  forceps  in 
hospital  during  the  last  ten  years,  I  know  of  three  in  which  the  uterus 
was  ruptured  in  that  part  of  the  posterior  wall  situated  over  the 
promontory,  and  I  know  of  several  cases  of  severe  bruisings  and 
tears  of  the  cervix  and  vagina.  Amongst  my  own  cases  in  one 
the  cervix  was  extensively  torn.  Altogether  there  is  a  morbidity  of 
18  per  cent.  In  my  cases  of  spontaneous  delivery  the  morbidity  is 
nil.  No  doubt  the  morbidity  in  the  forceps  cases  is  due  in  great  part 
to  the  fact  that  many  of  the  patients  were  examined  by  midwives  or 
careless  practitioners  before  admission  to  hospital ;  but,  even  allowing 
for  that,  it  is  too  large. 

Let  me  now  summarize  the  treatment  I  have  sketched  under  the 
two  following  headings : 

1.  Cases  in  which  the  deformity  is  recognized  during  pregnancy. 

2.  Cases  in  which  the  deformity  is  recognized  during  labour. 

1.  Cases  in  which  the  Deformity  is  recognized  during-  Preg*- 
nancy. — It  is  of  the  very  greatest  importance  to  bring  as  many  cases 
as  possible  into  this  group.  Medical  practitioners,  therefore,  whenever 
they  have  the  opportunity,  should  make  a  point  of  satisfying  them- 
selves of  the  pelvic  capacity  of  all  primigravidse,  and  of  multigravidae 
who  have  had  previous  difficulty  at  their  confinements.  It  is  well  that 
all  pregnant  women  should  appreciate  this  also,  especially  in  cities  such 
as  Glasgow  where  pelvic  deformities  are  common,  and  should  go  to 
their  medical  attendants  during  the  later  weeks  of  pregnancy.  I  need 
not  enlarge  upon  this  ;  it  is  admitted  by  everyone. 

The  accoucheur  in  a  case  of  suspected  deformity  should  measure 
the  pelvis  and  estimate  its  capacity.  He  should  then  place  the 
woman  amongst  those  of  slight,  extreme,  or  moderate  pelvic  deformity. 
The  exact  limits  of  these  different  groups  have  been  alread}^  given. 
Should  the  pelvis  be  of  slight  or  extreme  deformity,  pregnancy  is 
allowed  to  continue  until  near  term.  In  the  case  of  slight  deformity 
labour  is  allowed  to  come  on,  as  the  delivery  will  be  spontaneous,  or 
at  worst  will  be  terminated  by  forceps.  Should  the  deformity  be 
extreme,  however,  preparations  must  be  made  so  that  the  patient  is 
prepared  for  either  Csesarean  section  or  craniotomy,  should  the  child 
happen  to  be  dead. 

If,  however,  the  deformity  of  the  pelvis  is  only  moderate,  a  most 
careful  examination  of  the  relative  size  of  the  head  and  pelvis  should 
be  made  under  an  anaesthetic  in  the  thirty-fifth  or  thirty-sixth  week 
of  pregnancy.  The  object  of  this  is  to  give  an  opportunity  of  judging 
if  induction  of  labour  should  be  had  recourse  to.  If  this  operation 
is  decided  upon,  it  may  be  done  at  the  time,  or  delayed  a  week  to  ten 


198  OPERATIVE  MIJAVI 1  I  .l;Y 

days  if  deemed  advisable.  Should  the  case  be  considered  unsuitable 
for  induction  of  labour,  pregnancy  is  allowed  to  continue.  In  most 
cases  the  examination  will  have  shown  the  degree  of  disproportion 
between  the  head  and  pelvis,  and,  consequently,  whether  labour  is 
likely  to  terminate  spontaneously,  with  forceps,  or  with  Cesarean 
section.  If  there  is  any  doubt  about  this,  it  is  well  to  examine 
again  under  an  amesthetic  at  the  very  beginning  of  labour,  for  if 
Cesarean  section  is  to  be  performed,  it  is  undesirable  that  labour 
should  be  allowed  to  continue  for  any  length  of  time.  It  will  be 
observed  that  I  have  said  nothing  about  symphysiotomy,  and  for  the 
reason  that  I  consider  its  place  is  when  forceps  just  fails  to  effect 
delivery. 

When  Cesarean  section  is  deemed  unnecessary,  the  patient  must 
be  allowed  to  continue  in  labour,  and  every  opportunity  given  for 
spontaneous  delivery.  If  that  should  fail,  the  accoucheur  must  be 
prepared  for  either  forceps  in  the  Walcher  position  (Fig.  155)  or 
symphysiotomy  (pubiotomy)  if  the  child  is  living,  and  craniotomy  if 
the  child  is  dead. 

No  rule  can  be  laid  down  as  to  when  one  should  choose  Cesarean 
section  and  when  one  should  allow  labour  to  pursue  its  course ;  only 
experience  can  teach  one.  I  have  found  that,  with  only  a  slight 
degree  of  overlapping,  the  head  usually  moulds  sufficiently  to  allow 
of  delivery^'/-  vias  naturales.  If,  however,  by  pushing  the  head  into 
the  pelvis  the  latter  cannot  be  made  to  catch,  then  there  will  seldom 
be  sufficient  moulding  to  permit  of  easy  delivery  per  vias  naturales, 
and  consequently  the  accoucheur  should  choose  Ca-sarean  section. 

2.  Cases  in  which  the  Deformity  is  recognized  during  Labour. 
— In  hospital  and  in  the  poorer  districts  of  cities  a  large  number 
of  cases  belong  to  this  group.  Here,  again,  the  exact  amount  of 
deformity  should  be  estimated,  for  in  cases  of  extreme  and  slight 
deformity  it  will  always  guide  one  to  the  right  treatment.  Any 
difficulty  in  deciding  will  again  be  found  amongst  those  cases  in 
which  the  pelvis  is  only  moderately  deformed.  But  I  have  said 
enough  on  this  subject. 

There  is  only  one  other  point.  A  first  labour  is  a  trial  labour,  so 
with  moderate  pelvic  deformity  it  is  well  to  give  nature  every  possible 
chance.  One  takes  a  great  many  risks  for  the  child.  Induction  of 
labour  and  pubiotonry  are  seldom  suitable  operations,  while,  naturally, 
craniotomy  is  relatively  more  often  necessary. 

In  cases  which  come  under  one's  care  during  labour,  two  other 
factors  influence  one's  decision  regarding  treatment — viz.,  the  time 
labour  has  been  in  progress,  and  the  possibility  of  any  infection  of  the 
parturient  canal  having  occurred.     The  longer  labour  is  in  progress, 


TREATMENT  OF  CONTRACTED  PELVIS 


V.)U 


the  less  is  one  inclined  to  risk  the  mother's   life  by  such  a  major 
operation  as  Cesarean  section.     The  same  applies  to  cases  in, which 


Fig.  115.— The  Walcker  Position. 


there  is  a  possibility  that  infecting  organisms  have  been  introduced, 
as  when  the  woman  has  been  examined  by  a  dirty  midwife  or 
careless  practitioner. 


200  <>ri:i:  \tivk  midwifes? 

As  I  have  described  it,  the  treatment  of  contracted  pelvis  is 
simplicity  itself.  It  is  the  course  I  have  followed  in  hospital  and 
private  practice  for  many  years,  and  it  has  given  me  great  satis- 
faction. The  only  results  which  have  not  pleased  me  have  been 
those  from  forceps ;  but  during  the  last  few  years,  since  1  have 
insisted  that  my  assistants  must  never  employ  forceps  unless  they  are 
absolutely  sure  that  interference  is  indicated,  and  that  they  must  give 
the  second  stage  endless  time,  my  results  have  been  infinitely  better. 

There  should  be  no  maternal  nor  foetal  mortality  beyond  an 
occasional  one,  which  no  one  can  prevent.  Such  an  ideal  state  of 
matters  has  almost  been  reached  in  maternity  hospitals  in  cases 
which  have  not  been  interfered  with  prior  to  their  admission. 


CHAPTER  XIII 

DYSTOCIA  THE  RESULT  OF  ABNORMALITIES  AFFECTING  THE 
PARTURIENT  CANAL— Continued 

Abnormalities  in  the  Soft  Parts  :  Cervix— Vagina— Perineum. 

Pathological  conditions  of  the  cervical  and  vaginal  canals  are  com- 
paratively rare.  Doubtless  their  resistance  to  dilatation  varies  greatly, 
and  imperceptibly  influences  the  course  of  labour,  but  gross  abnor- 
malities which  one  can  appreciate  are  not  common. 

Taking  the  cervical  canal  first,  the  commonest  causes  of  dystocia 
are  rigidity,  stenosis,  and  atresia. 

Rigidity. — It  is  very  general  to  classify  rigidity  of  the  cervix  as 

follows : 

„     _         .  f  (a)  Inflammatory. 

1.  Organic.       -,  /1A  XT  ,, 

&  I.  (o)  New  growths. 

_    t,        ..       ,('(«)  Spasmodic  (trismus  uteri). 

2.  Functional  -   )'  nL      ...    ,.       . 

(  (b)  Constitutional. 

The  classification,  on  the  whole,  is  good,  although  I  am  inclined  to 
take  exception  to  the  group  termed  'constitutional,'  as  will  be  seen 
later. 

One  would  expect  that  inflammatory  affections  of  the  cervix,  which 
are  often  associated  with  great  thickening  and  elongation  of  the  canal, 
might  readily  cause  rigidity  and  retard  dilatation,  yet  in  practice  it  is 
surprising  how  hypertrophied  and  elongated  cervices  yield.  Even 
hard  cicatrices  soften  to  a  wonderful  extent  during  pregnancy  and 
parturition.  As  far  as  my  experience  goes,  the  only  interference 
called  for  has  been  pressing  the  lips  of  the  cervix  back  over  the 
presenting  part,  or  making  slight  incisions  into  them.  I  have  never 
required  to  amputate  a  hypertrophied  cervix,  but  if  necessary,  I  see 
no  objection  to  doing  it  during  labour.  Even  Cesarean  section  has 
been  performed  for  this  condition,  as,  for  example,  in  the  cases 
recorded  by  Ribemont-Dessaignes1  and  Rudaux.2     Hansson3  recom- 

1  Anal  de  Gyn.,  1905,  p.  121.  2  Ibid.,  p.  124. 

3  '  Festschrift,'  Otto  Engstrom,  Berlin,  1903. 

201 


2o-J  OPERATIVE  MIDWIFERY 

mends  the  .imputation  of  the  hypertrophied  cervix  daring  pregnancy, 
and  gives  three  cases;  the  pregnancy  was  interrupted  in  one,  but  in 
the  oilier  two  continued  undisturbed.  Potocki1  has  also  recorded 
a  case  which  proved  successful,  and  in  which  the  pregnancy  was  not 
disturbed.  It  is  interesting  to  know  that  this  operation  on  the  gravid 
uterus,  in  common  with  so  many  others,  can  be  performed  without 
the  pregnancy  being  interfered  with.  I  question,  however,  if  such 
treatment  is  indicated,  for  it  is  surprising  how  the  cervix  yields,  and, 
at  the  worst,  the  operation  could  be  performed  during  labour. 

A  very  troublesome  rigidity  occasionally  follows  the  use  of  caustics 
and  the  amputation  of  the  cervix.  Boissard  and  Coudert-and  Pinard, 
Segond,  and  Couvelare3  have  described  cases.  In  such  if,  after  a 
reasonable  amount  of  time,  dilatation  does  not  occur,  then  forcible 
stretching,  or,  better  still,  deep  incisions  of  the  cervix,  become  neces- 
sary. Indeed,  Cesarean  section  may  even  be  necessary,  as  in  the  case 
recorded  by  Studdiford.4 

The  two  other  forms  of  rigidity,  described  as  functional,  are  the  most 
common.  The  spasmodic,  which  in  its  most  marked  form  is  known  as 
'  trismus  uteri,'  is  found  in  nervous  primiparje  often  when  there  has 
been  premature  rupture  of  the  membranes,  or  as  the  result  of  some 
reflex  irritation — for  example,  overdistension  of  bowel  or  bladder.  It 
occurs  especially  during  the  early  stages  of  dilatation.  No  operative 
treatment  is  necessaiy,  and  manual  dilatation,  unless  the  patient  is 
anaesthetized,  only  aggravates  the  condition.  Any  reflex  irritation 
should  be  removed,  and  a  full  dose  of  opium  given.  I  prefer  Battley's 
solution  (liquor  opii  sedativus)  given  by  the  mouth,  but  tincture  of 
opium,  by  mouth  or  rectum,  or  a  morphia  suppository,  may  be  sub- 
stituted. Chloral  may  also  be  employed,  and  often  acts  very  well, 
although,  in  my  experience,  not  so  well  as  opium.  Hot  douches  also 
often  relieve  this  form  of  rigidity.  The  application  of  cocaine  to  the 
cervix  sometimes  acts  well.  The  cervical  surface  may  be  painted  over 
with  a  10  per  cent,  solution  of  the  chloride,  or,  better  still,  a  plug  of 
gauze  soaked  in  7  per  cent,  solution  of  the  chloride  may  be  inserted 
into  the  vagina.  The  injection  of  a  '■>  per  cent,  solution  directly  into 
the  cervix  by  means  of  a  long  needle  has  also  been  recommended. 
I  have  never  employed  extract  of  belladonna  as  a  substitute. 

But  there  is  another  form  of  rigidity  very  occasionally  encountered 
which  yields  to  no  treatment.  Cocaine  maybe  applied  locally,  opium, 
chloral,  or  any  other  drug  may  be  administered  internally,  hot  douches 

1  Annul .  dc  (li/n.,  December,  1906,  p.  709. 
-  L'Obstetriqiu ,  January,  1004. 

3  Annul,  (h   (iiju.,  December.  lUUi'i.  p.  70."i. 

4  Amer.  Journ.  Obat.,  September,  1909. 


RIGIDITY  OF  THE  CERVIX  203 

and  baths  may  be  given,  without  producing  the  slightest  effect  upon  the 
cervix.  To  this  form  the  name  of  '  constitutional  rigidity'  is  generally 
given.  The  term  has  always  appeared  to  me  a  misnomer,  as  I  do  not 
believe  it  is  functional,  but  rather  the  result  of  some  pathological  con- 
dition of  the  cervix.  It  is  not  peculiar  to  old  primiparae,  as  is  some- 
times stated ;  indeed,  the  worst  cases  I  have  seen  were  in  primiparae  of 
little  over  twenty-five  years  of  age.  Nor  is  it  found  associated  with 
any  particular  habit.  The  delay  in  dilatation  in  this  form  is  some- 
times extreme.  In  one  case  recently  seen  the  patient  was  four  days 
in  labour,  with  strong  uterine  contractions  coming  on  every  ten 
minutes ;  finally,  the  labour  had  to  be  terminated  by  making  incisions 
into  the  cervix. 

In  such  cases  no  medicinal  treatment  does  any  good.  A  sufficient 
time  having  been  given,  incisions  or  forcible  dilatation  of  the  cervix 
with  the  hands  or  a  dilator,  or,  better  still,  the  introduction  of 
a  hydrostatic  bag,  are  the  only  means  at  one's  disposal,  and  in  such 
cases  I  would  advise  against  too  long  delay.  If  the  patient's  tempera- 
ture or  pulse  begins  to  rise,  or  if  the  fcetal  heart  becomes  affected, 
interfere  immediately.  Personally,  in  such  cases  I  believe  incisions 
are  better  than  forcible  dilatation.  Both  methods  of  treatment  are 
discussed  under  Accouchement  Force  (Chapter  XXVIII.). 

(Edema. — A  very  simple  form  of  obstruction  connected  with  the 
cervix  is  oedema  of  the  anterior  lip,  which  is  produced  by  pressure  of 
the  lip  between  the  presenting  head  and  symphysis.  I  have  occasion- 
ally seen  a  swelling  as  large  as  a  Tangerine  orange  result.  It  is  very 
seldom  necessary  to  puncture  the  cedematous  lip,  for  it  is  nearly  always 
possible  to  push  it  back  over  the  head.  It  very  seldom  fails  if  carried 
out  during  a  uterine  contraction,  and  if  two  fingers  are  employed. 

An  acute  cedema  of  the  cervix  and  surrounding  parts  has  been 
occasionally  referred  to.  Geyl1  considered  the  subject  very  fully,  and 
Jolly2  has  discussed  it  recently.  It  is  a  condition  which  was  first 
described  by  Gueniot.  It  generally  occurs  in  pregnancy  and  in  those 
cases  where  a  prolapse  of  the  uterus  existed.  A  case  of  the  kind  was 
admitted  to  my  ward  recently.  The  woman  had  reached  term.  Shortly 
after  some  slight  straining  effort  an  enormous  cedematous  condition  of 
the  cervix  developed.  The  swelling  was  the  size  of  a  Jaffa  orange, 
and  projected  from  the  vulva.  In  a  couple  of  days  it  had  almost 
entirely  disappeared,  and  she  gave  birth  to  a  normal- sized  child  with- 
out an  operative  interference.  An  interesting  case  is  described  by 
Seitz  3  where  the  condition  appears  to  have  been  produced  by  obstinate 
constipation.     Sometimes  an  oedema  affecting  the  whole  cervix  follows 

1  Volkmann's  Samml.  Klin.  Vortrage,  189-3,  No.  128. 

-  Zeit.f.  Geb.  u.  Gyn.,  Bd.  hi.,  Heft  3.  3  Zent.f.  Gyn.,  190,1,  p.  289. 


204  OPERATIVE   MlhWIEKEY 

a  prolonged  labour.  Especially7  is  this  seen  in  cases  of  contracted 
pelvis. 

(Edema,  which  so  often  affects  pregnant  women,  may  occasionally 
be  specially  pronounced  in  the  parts  about  the  vulva,  more  par- 
ticularly the  labia.  Such  a  condition  may  occasionally  interfere 
with  parturition.  If  pressure  does  not  remove  it,  multiple  punctures 
should  be  made. 

New  growths  of  the  cervix  are  rarely  found  complicating  labour, 
and  practically  the  only  two  varieties  met  are  myomata  and  carcino- 
mata.  The  whole  subject  of  tumours  complicating  labour  is  con- 
sidered elsewhere.  An  extremely  rare  occurrence  is  hsematoma  of  the 
cervix.  Barnes1  describes  a  case  in  which  he  mistook  such  a  tumour 
for  an  inverted  uterus.  The  subject  of  hematoma  is  considered  later 
in  this  chapter. 

Atresia. — Atresia  of  the  whole  cervix  complicating  labour  must  be 
extremely  rare.  Adhesion  of  the  membranes  to  the  lower  part  of 
the  uterus,  preventing  dilatation  of  the  internal  os,  is  probably  the 
commonest  cause  of  atresia.  In  passing,  let  me  remark  that  this 
condition  has  often  appeared  to  me  to  be  a  cause  of  rupture  of  the 
membranes  before  or  early  in  labour. 

Atresia  of  the  external  os  (conglutinatio  orificii  externi)  is  not 
uncommon,  and  several  cases  have  occurred  in  the  Glasgow  Maternity 
Hospital.  In  the  simpler  forms  only  the  mucous  membrane  is 
agglutinated,  although  in  some  cases  fibrous  tissue  is  actually  found 
present.  The  cause  must,  of  course,  have  been  some  slight  inflam- 
matory mischief  during  the  pregnancy,  although,  as  a  rule,  no  history 
of  such  a  condition  can  be  elicited.  Usually  one  can  make  out  a 
slight  dimple,  which  indicates  the  position  of  the  os,  but  sometimes 
no  trace  of  the  latter  can  be  detected. 

The  obstruction  may  be  so  slight  that  the  uterine  contractions 
overcome  the  obstruction  ;  on  the  other  hand,  it  may  be  so  persis- 
tent that  the  thinned-out  vaginal  portion  may  be  carried  away  by  the 
presenting  part.  The  condition  is  readily  recognized  if  a  careful 
examination  is  made.  If,  however,  the  examination  is  made  casually, 
the  thinned-out  cervix  may  be  overlooked,  and,  the  landmarks  of  the 
head  being  so  distinctly  felt  through  the  thinned  cervix,  the  condition 
may  be  taken  for  a  full  dilatation  of  the  os.  Not  very  long  ago  a  case 
was  reported  where  this  mistake  was  made,  and  forceps  were  applied, 
with  great  laceration  to  the  vaginal  vault,  followed  by  the  death  of  the 
patient.  A  colleague  informed  me  that  he  was  about  to  introduce  the 
blades  of  the  forceps  in  a  case  of  the  kind,  when,  finding  that  he  could 
not  feel  the  lips  of  the  os,  he  made  a  more  careful  examination  and 
1  '  Obstetric  Operations,'  p.  472. 


ATRESIA  OF  THE  CERVIX 


205 


discovered  that  the  os  was  not  dilated.  In  such  cases  one  can  trace 
the  smooth  vaginal  surface  over  the  head,  and  the  fingers  become 
arrested  in  the  fornices. 

In  treating  this  condition,  all  that  is  necessary  is  to  make  a 
crucial  incision,  and  I  prefer  to  do  this  after  labour  has  been  in 
progress  and  during  a  uterine  contraction,  when  the  part  is  on  the 
stretch.  If  recognized  during  pregnancy,  it  is  better  not  to  interfere.  It 
is  sometimes  not  even  necessary  to  make  incisions ;  the  tips  of  the  fingers 
or  the  point  of  a  dilator  is  sufficient  to  remove  the  obstruction,  after 


Fig.  116. — The  Anterior  Lip  of  the  Cervix,  very  much  thinned  out,  with  the 
Os  Externum  but  little  dilated  high  up  in  the  Posterior  Fornix. 


which  Nature  completes  the  dilatation  herself.  It  is  surprising  in  these 
cases  where  incisions  are  made  that  there  should  be  so  little  tearing 
of  the  cervix.  In  several  cases  I  have  carefully  examined  the  cervix 
after  delivery,  and  found  wonderfully  little  laceration.  Of  course,  if 
extensive  tearing  does  result,  the  laceration  must  be  carefully  stitched. 
A  condition  somewhat  similar  is  where  the  anterior  lip  becomes 
very  thinned  out,  and  where  at  first  no  os  can  be  detected.  On  more 
careful  examination  it  is  found  away  up  behind  (Fig.  116).  This 
condition  is  sometimes  referred  to  as  a  backward  displacement  of  the 


206  OPERATIVE  MIDWIFERY 

os,  but  the  expression  is  incorrect,  for  it  is  really  an  undue  stretch- 
ing of  the  anterior  wall.  A  corresponding  condition  of  the  posterior 
wall  with  the  os  high  up  in  front  I  have  never  seen  ;  it  is,  however, 
described. 

I'pon  three  occasions  I  have  observed  a  cervix  in  which  there  was 
neither  rigidity  nor  atresia  of  the  os,  and  yet  the  cervix  would  not 
dilate.  The  curious  feature  in  such  cases  (the  women  were  all  primi- 
gravidse)  was  that  the  os  could  be  stretched  with  the  greatest  i 
It  felt  as  if  there  was  a  circular  thread  preventing  dilatation.  It 
appeared  to  me  like  the  open  mouth  of  a  muslin  bag  drawn  in  by  a. 
tine  thread  ;  break  the  thread,  and  the  bag  can  be  immediately  opened. 
I  was  interested  to  find  that  Yon  Bardeleben1  refers  to  two  similar 
cases  where  the  os,  from  being  very  small,  was  dilated  by  the 
finger  '  wie  eine  Irisblende  '  in  two  and  one  and  a  half  minutes 
respectively. 

Vaginal  and  Vulvar  Obstruction. — Obstruction  in  the  vagina 
is  less  common  than  obstruction  in  connexion  with  the  cervix. 
Occasionally  rigidity  of  the  canal  is  encountered — more  commonly, 
it  is  said,  in  old  primiparze,  but  I  have  found  it  not  infrequently  an 
individual  peculiarity,  and  quite  independent  of  the  age  of  the  par- 
turient. A  localized  atresia,  and  still  more  a  stenosis,  is  very  rare. 
I  have  occasionally  encountered  the  former  where  there  had  been 
severe  laceration  at  a  previous  confinement;  and  I  had  in  my  hospital 
practice  a  case  where  there  was  only  a  small  opening  through  a 
diaphragm  situated  about  the  junction  of  the  middle  and  upper 
thirds  of  the  vagina.  Sometimes,  as  in  a  case  reported  by  Heywood 
Smith,2  no  opening  can  be  discovered,  although  a  small  opening  must, 
of  course,  have  existed  prior  to  conception. 

Cicatrices  and  adhesions  between  the  anterior  and  posterior  walls 
of  the  vagina  occasionally  result  from  the  application  of  caustic-, 
from  the  specific  fevers,  more  especially  diphtheria  and  scarlet  fever, 
and  syphilitic  affections,  and  from  previous  injuries.  Fournier3  and 
Alontini4  record  cases  of  extreme  vaginal  obstruction  following  vesical 
fistula  ;  in  both  hysterectomy  was  necessary.  Neugebauer5  gives 
very  complete  summaries  of  the  cases  recorded  to  date.  In  a  few 
the  obstruction  was  congenital,  and  in  them  the  atresia  was  very 
localized. 

i  Archiv  f.  Gijn.,  1905,  Bd.  lxxvi.,  Heft  1,  p.  159. 

-  Obstet.  Trans.,  vol.  xxiii.,  p.  117.  3  L'Obstetrique,  1904,  No.  2. 

4  'La  Ginecologia,'  Kef.  Joitm.  Obstet.  and  Qyn,  Brit.  Empire,  April,  1906, 
p.  291. 

■  "  Zur  Lehre  von  den  angeborenen  und  erworbenen  Verwachsungen  und 
Verengerungen  der  Scheide,'  Berlin,  1895. 


STENOSIS  OF  THE  VAGINA  207 

Some  time  ago  I  saw  a  case  in  consultation  where  a  band  obstructed 
labour.  It  proved  to  be  the  remains  of  the  vaginal  septum  of  a  uterus 
didelphys.  The  foetal  head  had  passed  through  the  septum,  but 
further  progress  was  arrested  by  the  shoulders  being  caught  by  it. 
After  division  of  the  band,  delivery  of  the  child  was  easily  accom- 
plished. Similar  cases  have  been  recorded  by  Budin,  Jacobs,  and 
others. 

It  sometimes  happens  that  the  hymen  is  not  lacerated  during 
intercourse,  and  remains  more  or  less  intact  and  obstructs  the  escape 
of  the  child.  In  one  or  two  cases  the  hymen  has  been  completely 
imperforate,  the  small  opening  which  previously  existed  having  become 
closed  during  pregnancy. 

Hard-and-fast  rules  cannot  be  laid  down  as  regards  treatment. 
In  most  cases  cicatrices  yield  sufficiently,  and,  consequently,  it  is  not 
advisable  to  interfere  during  pregnancy.  When  they  are  very  exten- 
sive, or  when  bands  or  a  diaphragm  exist,  incisions  may  be  necessary. 
If  the  obstruction  is  very  localized,  incisions  may  be  easily  and  safely 
made;  but  if  extensive,  and  especially  if  cicatricial,  they  must  be 
made  very  cautiously,  and  with  due  regard  to  the  danger  of  injuring 
bladder  or  rectum.  The  incisions  may  be  made  on  either  the  anterior 
or  posterior  walls,  but  those  on  the  anterior  must  not  be  deep.  Those 
on  the  posterior  wall  may  be  made  much  deeper,  and  it  is  well  to  pass 
two  fingers  high  up  into  the  rectum  and  cut  to  the  side,  in  order  to 
avoid  the  bladder  and  rectum  as  far  as  possible.  Speaking  generally, 
one  should  delay  making  incisions  until  the  obstructing  band  or 
diaphragm  is  put  on  the  stretch  by  the  presenting  part.  As  I  have 
said  already,  it  is  surprising  how  even  extensive  cicatrices  yield. 

Where  the  obstruction  is  so  extreme  as  to  render  the  extraction 
of  the  child  impossible  without  extensive  tearing  occurring,  Cesarean 
section  is  the  only  alternative,  as  in  Fournier's  case  already  referred 
to.  Where  the  hymen  remains  intact,  incisions  must  be  made,  after 
which  it  will  often  be  found  necessary  to  deliver  the  child  with  forceps. 

The  most  common  site  of  obstruction  in  the  soft  parts,  at  least  of 
primiparae,  is  the  perineum  and  vulvar  orifice.  Where  this  is  due  to 
special  development  of  the  muscles  of  the  pelvic  floor,  the  obstruction 
is  readily  removed  by  opium  or  disappears  under  chloroform  anaes- 
thesia, for  it  is  only  spasmodic  rigidit}^.  Where,  however,  the  tissues 
are  at  fault,  nothing  is  of  any  service.  Fomenting  the  perineum  by 
the  application  of  hot  cloths  I  have  not  found  do  any  good.  Indeed, 
I  sometimes  think  it  does  harm,  and  renders  the  tissues  more  liable 
to  tear.  Nor  do  I  think  that  manual  dilatation  of  the  vulvar  orifice, 
although  a  method  of  great  antiquity,  is  desirable  or  of  any  great 
service.     As  much   time  as   possible  should  be  given   the  head  to 


208 


<>ri:i;\Ti\K  midyvifkiiy 


distend  the  perineum.     But  if  that  is  insufficient,  a  lateral  incision  of 
the  perineum  should  he  made  (episiotomy). 

In  some  few  cases  I  have  seen  the  other  extreme  of  the  perineum 
relaxing  too  much  and  sagging,  with  the  result  that  the  head  is  not 
directed  upwards  round  the  symphysis.  The  trouble  in  such  cases 
is  at  the  vulvar  orifice,  which  does  not  sufficiently  dilate.  '  Central ' 
perineal  laceration  is  liable  to  occur.    In  such  cases,  if  pressure  on  the 


FlG.  117. — Small  Cyst  of  Vulva,  which  obstructed  the  Parturient  Canal  and  had  to 
be  enucleated  before  the  Child  could  be  delivered. 


perineum   is   not    sufficient,  incision   is  the   onty   thing   which    will 
prevent  an  extensive  perineal  laceration. 

Tumours  of  Vagina  and  Vulva. — Although  I  have  seen  many 
cases  of  cysts  of  the  vagina  and  vulva,  and  a  few  solid  tumours  of  the 
vagina,  only  upon  two  occasions  have  I  encountered  them  in  pregnant 
women.  Fig.  117  is  an  illustration  of  one  case.  In  the  other  the 
tumour  was  smaller.  In  both  the  cysts  were  enucleated  prior  to  the 
application  of  forceps.  Solid  tumours  are  easily  shelled  out,  but 
cysts,  as  they  have  such  thin  walls,  are  more  difficult  to  enucleate, 


HEMATOMA  OF  THE  PAETUEEENT  CANAL  209 

and  often  rupture  during  the  process.  The  tumours  should  always 
be  removed  prior  to  the  extraction  of  the  child. 

A  very  unfavourable  condition  is  an  abscess  of  the  vulvar  orifice, 
most  commonly  of  Bartholin's  glands.  I  have  only  had  one  case 
of  the  kind,  and  upon  that  occasion  I  excised  the  whole  gland.  In 
such  cases  there  is  a  very  great  danger  of  the  parturient  canal  being 
infected,  as  occurred  upon  two  occasions  in  the  Glasgow  Maternity 
Hospital. 

I  am  not  aware  of  any  cases  of  dystocia  from  vesical  calculus 
having  occurred  in  the  Hospital.  The  older  writers  frequently  refer 
to  it.  One  of  the  most  interesting  cases  is  recorded  by  Smellie,1 
where  a  large  vesical  calculus  was  discharged  during  labour.  A 
permanent  fistula  followed.  The  subject  of  vesical  calculus  and  other 
pathological  conditions  of  the  bladder,  causing  dystocia,  are  referred 
to  elsewhere. 

The  diagnosis  of  these  different  conditions  is  not  difficult  as  a  rule, 
and  the  determining  as  to  whether  a  tumour  is  situated  in  the  vaginal 
wall  itself  or  in  bladder  or  rectum  should  not  cause  much  trouble. 
Occasionally,  however,  tumours  situated  posterior  to  the  vaginal  canal 
may  really  be  intraperitoneal  tumours  of  ovary  or  uterus  pushed  down 
into  Douglas'  pouch  between  vagina  and  rectum ;  such  cases  are 
referred  to  in  Chapter  XV. 

Hsematoma  of  the  Parturient  Canal. 

All  who  have  had  an  extensive  experience  of  obstetric  practice  must 
have  encountered  hsematoma  of  the  vulva  as  a  complication  of  preg- 
nancy, labour,  or  the  puerperium,  for  although  not  common,  it  occurs 
about  once  in  1,500  or  2,000  cases.  But  what  is  not  fully  appreciated 
is  that  sometimes  the  effusion  of  blood  occurs  higher  up  into  the  loose 
cellular  tissue  about  the  vagina  and  uterus,  and  gives  rise  to  a  con- 
dition serious  by  reason  of  the  amount  of  blood  effused  and  difficult 
of  recognition. 

The  extent  of  the  effusion  varies  greatly,  and  does  not  always 
depend  upon  the  disposition  of  the  various  layers  of  fascia.  Certainly, 
if  the  haemorrhage  occurs  below  the  pelvic  fascia,  as  it  does  in  most 
cases,  the  amount  will  be  comparatively  small  and  localized  to  the 
vulva,  lower  part  of  the  vagina,  and  rectum.  On  the  other  hand,  if 
the  effusion  is  above  the  pel\ic  fascia,  it  usually  remains  localized 
to  the  lower  part  of  the  broad  ligament  and  surrounds  the  upper 
part  of  the  vagina.  Occasionally,  as  there  is  no  hindrance,  the 
effusion  extends  up  in  front  of  uterus  and  bladder,  as  in  Williams' - 

1  Smellie's  'Midwifery,'  McClintock,  vol.  ii.,  Case  60,  p.  1000. 

2  Trans.  Amer.  Gvn.  Soc,  1904. 

14 


210  OPERATIVE  Mll)\\Il'i:i;v 

case,  where  a  fluctuating  tumour  appeared  above  the  symphysis  pubis, 
extended  outwards  into  the  broad  Ligament  and  upwards  towards  the 

kidney.  In  some  cases  the  pelvic  fascia  offers  no  harrier,  and  the 
effusion  has  heen  found  to  extend  from  the  labium  up  to  and  behind 
the  kidney,  and  even  over  the  lower  anterior  part  of  the  abdomen. 

I  hematoma  of  the  vagina  is  most  frequently  recognized  after 
delivery.  In  the  seven  cases  which  have  heen  under  my  care  it  has 
occurred  twice  during  pregnancy,  and  five  times  it  was  only  recognized 
after  delivery.  According  to  Perret,1  in  forty- three  cases  it  happened 
twice  during  pregnancy,  six  times  during  labour,  and  thirty-live 
times  during  the  puerperium.  Of  special  interest  is  the  case  recorded 
by  Sasanoff,2  where  a  haematoma  formed  in  the  interval  between  the 
birth  of  twins.     Sasanoff  collected  five  similar  cases. 

The  general  explanation  given  of  the  condition  is  that  it  results 
from  the  giving  way  of  large  varicose  veins  commonly  found  around 
the  uterus,  vagina,  and  vulva.  That  explanation,  however,  is  ques- 
tioned by  many,  and  long  ago,  Perret,  in  a  case  which  terminated 
fatally,  proved  that  it  was  capillary  in  origin  by  injecting  first  from 
the  vein  and  then  from  the  artery.  Croom,3  in  recording  three  cases, 
considered  the  etiology  of  the  condition,  and  came  to  the  conclusion, 
which  was  practically  that  of  Perret,  that  bruising  and  dragging  on 
the  tissue  during  labour  resulted  in  tearing  of  the  tissue  and  the  fine 
capillaries.  As  Barnes4  very  naively  puts  it,  '  There  is  a  glacier-like 
movement  of  the  mucous  membrane  upon  the  subjacent  tissue.' 

It  is  generally  stated,  and  one  would  expect  that  it  should  be  so, 
that  laborious  and  difficult  labours  favour  the  occurrence  of  hematoma. 
Nevertheless,  in  quite  a  number  of  cases  those  conditions  have  not 
been  present,  and,  as  my  own  two  cases  and  many  others  prove, 
it  is  not  very  uncommon  in  pregnancy.  Occasionally,  in  the  ex- 
ternal variety,  direct  injuries,  resulting  from  blows,  falls,  etc.,  may 
produce  it. 

As  regards  the  other  variety,  the  subperitoneal  ha?matoma,  Williams, 
who  recently  described  the  case  already  referred  to  and  analysed  the 
records  of  thirty-three  others  collected  from  the  literature,  found  the 
following  conditions  :  In  63  per  cent,  the  women  were  pregnant  for 
the  first  time,  and  in  NO  per  cent,  the  labour  was  spontaneous  ; 
the  weight  of  the  children  was  somewhat  below  the  normal. 

The  symptoms  of  hematoma  are  severe  pain  of  a  tearing  character 
and,  in  the  superficial  variety,  bearing  down  and  tenesmus  of  the 

1  Tarnier  and  Budin,  '  Train'  d' Accouchement,'  vol.  iii. 

-  Annal.de  Ghyn.,  December,  1884. 

3  E<lin.  Med.  Jnnm..  L898,  vol.  xxxi.,  p.  1001. 

1  •  obstetric  Operation^,'  L886,  )».   17  1. 


HEMATOMA  OF  THE  PARTURIENT  CANAL  211 

bowel.  It  is  frequently,  but  not  always,  sudden  in  origin,  and  is 
followed  by  collapse  if  the  haemorrhage  is  extensive.  Naturally, 
collapse  will  be  a  more  prominent  symptom  with  subperitoneal 
hematoma,  in  which  the  loss  of  blood  is  generally  greater,  than  with 
the  ordinary  vulvar  or  vaginal  variety. 

The  tumour,  when  visible,  as  in  the  vaginal  or  vulvar  forms, 
presents  a  typical  purple  and  glistening  appearance,  and  is  tender 
and  elastic  to  the  touch.  The  surrounding  parts  are  displaced, 
especially  in  cases  where  the  effusion  is  subperitoneal.  With  the 
latter  the  uterus  is  displaced  in  various  directions,  forwards,  back- 
wards, or  to  the  side,  according  to  the  situation  of  the  tumour.  The 
vaginal  vault  becomes  obliterated.  In  extreme  cases,  where  the 
amount  of  blood  is  great,  a  wave  of  fluctuation  may  be  elicited  over 
the  lower  part  of  the  abdomen. 

The  diagnosis  of  the  exact  nature  of  the  condition  is  quite  simple 
in  cases  of  the  vulvar  variety.  With  the  vaginal  variety,  however, 
confusion  may  arise  with  an  inversion  of  the  uterus  or  a  large  sub- 
mucous myoma  protruding  from  the  os ;  but  only  if  the  examination 
is  very  casual  should  any  mistake  be  made,  for  an  inverted  uterus  or 
a  myoma  is  a  body  quite  distinct  from  the  vaginal  walls. 

With  subperitoneal  hematoma  it  is  very  different.  Incomplete 
rupture  of  the  uterus  may  present  symptoms  very  similar,  and  as 
Williams  says,  '  It  is  impossible  to  distinguish  the  condition  from  a 
hematoma  following  an  incomplete  rupture  of  the  uterus  without  a 
careful  exploration  of  the  lower  uterine  segment.' 

The  prognosis  in  the  ordinary  vaginal  and  vulvar  haamatoma  is 
good,  absorption  usually  taking  place.  Infection,  however,  may 
occur,  and  then  an  extensive  suppurating  wound  results,  with  all  the 
dangers  of  general  infection.  Rupture  not  infrequently  occurs,  with 
hemorrhage,  in  some  cases  severe,  in  others,  as  in  one  recently  under 
my  care,  very  gradual,  owing  to  the  smallness  of  the  opening.  In  my 
patient's  case  the  slow  oozing  had  greatly  exhausted  her,  and  she  was 
brought  into  hospital  very  collapsed.  Death  has  happened  on  several 
occasions. 

The  accepted  treatment  of  vulvar  and  vaginal  hematoma  is  very 
simple.  Absolute  rest  in  bed  is  all  that  is  deemed  necessary,  for  the 
effusion  is  usually  absorbed.  When,  however,  there  is  a  constant 
trickling  of  blood  from  the  sac,  it  is  well  to  split  open  the  sac,  clear 
out  the  blood-clot,  and  pack  the  sac  with  gauze.  The  same  treatment 
should  be  employed  in  those  rare  cases  where  the  hematoma  occurs 
during  pregnancy  or  labour,  and  actually  interferes  with  the  escape 
of  the  child.  It  is  always  bad  obstetrics  to  drag  the  child  past  the 
tumour. 


212 


OPERATIC  E  MIDWIFERY 


Should  the  hematoma  become  infected,  it  is  better  to  empty  the 
sac  and  drain  the  cavity  with  gauze.  In  such  cases  very  extensive 
destruction  of  the  tissue  may  occur,  as  in  a  case  under  my  care  some 


Tu..   US.— Large  Hematoma  ■  >f  Vulva.     (Author's  Case.) 
One  end  of  the  piece  of  gauze  Bhofl  o  has  been  pushed  iuto  the  vagina. 

years  ago  (Fig.  118)  ;  the  ha-matoma  became  infected,  and  the  whole 
perineal  body  sloughing,  a  large  suppurating  cavity  formed,  into  which 
the  bowel  and  vagina  opened. 

The  treatment  which  has  been  sketched  is  that  which  has  been 
generally  recommended  for  many  years.     I  am  inclined  to  agree  with 


HEMATOMA  OF  THE  PARTURIENT  CANAL  218 

Walthard,1  however,  that  we  might  now  in  many  cases  go  a  step  farther 
and  treat  the  condition  surgically,  without  waiting  for  indications  such 
as  haemorrhage  and  suppuration — at  least,  in  the  cases  which  develop 
during  or  after  delivery. 

The  subperitoneal  hematoma  of  an  extensive  nature  is  upon  quite 
another  footing.  Expectancy  in  this  variety  may  be  fatal,  and,  indeed, 
in  past  years,  often  has  been.  The  sac  must  be  opened  from  the 
abdomen,  the  fluid  and  coagulated  blood  cleared  out,  and  the  cavity 
packed  with  gauze.  The  alternative  of  attacking  the  effusion  from 
the  vagina  is  less  favoured,  although  there  is  no  doubt  that  one 
obtains  better  drainage  by  such  a  route ;  it  should  be  adopted  in  those 
cases  where  the  effusion  involves  chiefly  the  tissues  of  the  pelvis. 
The  case  recorded  by  Walthard  illustrates  this. 

1  Zent.  f.  Gyn.,  1905,  p.  919. 


CHAPTER  XIV 

DYSTOCIA  THE  RESULT  OF  ABNORMALITIES  AFFECTING  THE 
PARTURIENT  CANAL— Contin 

Carcinoma  of  the  Cervix. 

Another  variety  of  tumour  which  is  occasionally  found  complicating 
pregnancy  or  causing  dystocia  is  carcinoma  of  the  cervix.  The 
complication  is  a  rare  one.  In  the  Glasgow  Maternity  Hospital  the 
frequency  has  been  about  1  in  2,000.  Sarwey  puts  the  frequency 
at  1  in  2,000,  and  Glochner,  for  Zweifel's  Klinik  in  Leipzig,  at 
1  in  1,500. 

The  reasons  for  its  comparative  rarity  are  obvious.  Carcinoma  of 
the  cervix,  although  not  peculiar  to  the  later  years  of  reproductive 
life,  more  commonly  appears  then.  Again,  the  growth  itself,  and  the 
•harge  which  so  frequently  accompanies  the  disease  when  advanced, 
to  some  extent  acts  as  a  barrier  to  pregnancy,  although  I  do  not 
believe  the  disease  in  the  early  stages  prevents  conception.  I  know 
no  one  who  supports  the  old  view  of  Cohnstein1  that  the  growth 
favours  the  occurrence  of  pregnancy. 

As  regards  the  influence  of  pregnancy  upon  the  tumour,  and. 
vice  versa,  of  the  tumour  on  the  pregnancy,  only  a  word  or  two  is 
necessary.  Most  authorities  teach  that  the  growth  advances  more 
rapidly  in  the  gravid  than  in  the  non-gravid  uterus.  Recently, 
however,  Pinard  took  exception  to  this  view.-  Personally,  I  have 
only  one  case  to  judge  by — a  woman  with  an  inoperable  carcinoma 
whom  I  watched  during  the  last  few  months  of  her  pregnancy.  In 
her  case  I  was  not  struck  by  any  rapid  increase  of  the  tumour 
during  that  time.  On  the  face  of  it,  one  would  expect  the  disease 
to  advance  more  rapidly  if  the  uterus  were  gravid,  for  the  parts  are 
more  vascular  and  the  cellular  tissue  is  looser.  However,  it  is  not  a 
matter  of  very  great  importance,  for  it  does  not  in  any  way  affect 
the  treatment. 

1  Archiv  f.  Gyn..  Bd.  v..  p.  336.  2  Annal.  dc  Gyn..  1901.  p.  309. 

214 


CAKCINOMA  OF  THE  CERVIX  -215 

Most  modern  writers,  including  Bar1  and  Condamin2  agree  with 
the  older  statement  of  Cohnstein  that  the  presence  of  malignant 
disease  of  the  cervix  predisposes  to  abortion  ;  not  only  so,  but  that 
the  mortality  amongst  foetuses  which  have  reached,  or  nearly  reached, 
term  is  unusually  high,  according  to  Theilhaber  as  high  as  47  per 
cent.  My  experience  is  one  dead  fcetus  in  five,  and  my  colleague's 
results  have  been  equally  good,  so  that  I  cannot  agree  with  Theilhaber. 
I  cannot,  however,  go  to  the  other  extreme,  as  some  have  done,  and 
say  that  the  disease  does  not  predispose  to  abortion  or  death  of  the 
fcetus.  for  it  is  inconceivable  that  the  disease  has  no  effect  on  these 
occurrences. 

But  if.  as  almost  all  admit,  the  presence  of  carcinoma  of  the  cervix 
affects  pregnancy  but  little,  there  is  not  the  least  doubt  that  in  many 
cases  it  influences  labour  very  adversely.  Naturally,  the  cases  most 
affected  are  those  in  which  the  disease  is  far  advanced,  for  then  the 
dangers  most  dreaded — hemorrhage,  rupture  of  the  uterus,  and  septic 
infection — are  liable  to  occur. 

The  diagnosis  of  carcinoma  cervicis  (Fig.  119)  seldom  presents 
greater  difficulty  in  the  gravid  than  in  the  non-gravid.  In  both  it 
is  easy  of  recognition  when  at  all  advanced,  and  very  difficult  when 
the  disaase  is  still  at  an  early  stage.  The  only  reliable  test  is  a  care- 
ful microscopic  examination  of  the  cervical  tissue.  There  is  one  point 
of  great  importance,  however.  The  healthy  cervix  always  becomes 
much  softened  during  pregnancy,  but  the  carcinomatous  tissue  does 
not  altogether  share  in  the  softening.  Consequently,  the  presence  of 
any  hard  tissue  in  the  cervix  of  a  woman  advanced  in  pregnancy,  or 
in  labour,  should  always  arrest  attention,  and  one  should  test  its 
friability,  either  with  the  fingers  or  curette,  and  remove  a  small 
portion  of  the  tissue.  In  a  case  recently  placed  under  my  care  the 
medical  practitioner  who  sent  the  patient  to  me  correctly  diagnosed 
the  condition  by  the  hardness  of  the  cervix.  This  and  the  hemorrhage 
on  touching  the  cervix  were  the  only  symptoms. 

As  in  carcinoma  cervicis  generally,  the  most  difficult  cases  to 
diagnose  are  those  in  which  the  disease  has  originated  in  the  cervical 
canal.  In  most  of  these,  however,  the  disease  is  so  far  advanced 
that  there  is  an  ulcerated  surface,  and  so  the  diagnosis  is  evident. 
Hemorrhage,  if  the  disease  has  advanced  to  any  extent,  is  always  a 
symptom,  and  must  never  be  neglected.  No  matter  how  slight  the 
hemorrhage  may  be,  its  cause  must  always  be  searched  for,  because 
during  pregnancy  there  should  be  absolutely  no  sanguineous  dis- 
charge, and  at  the  commencement  of  labour  it  should  be  very  slight. 
Several  writers  have  mentioned  the  frequency  of  pain  and  the  early 
1   These,  Paris,  1889.  -  Annal.  de  Gyn.,  March,  1905,  p.  129. 


216 


OPERATIVE  MIDWIFERY 


appearance  of  it  in  the  course  of  the  disease  ;  in  my  five  cases  it  was 
not  a  feature. 

A  point  of  great  interest,  and  one  which,  as  far  as  J  can  gather 
from  the  literature  of  the  suhject,  has  not  been  emphasized,  is  that 


Fig.  119. — Carcinoma  Oervicis.     (Author's  Collection.) 
Child  extracted  l>y  Cesarean  section,  ami  uterus  removed  per  vaginam. 

the  proportion  of  operable  cases  amongst  the  gravid  is  much  greater 
than  amongst  the  non-gravid.  The  terms  '  operable  '  and  '  inoperable  ' 
as  applied  to  carcinoma  of  the  cervix,  are  presumably  well  understood. 
The  former  implies  that  the  operator  considers  it  possible  to  remove 


CARCINOMA  OF  THE  CERVIX  217 

the  uterus  and  tumour,  and  the  latter  that  he  considers  it  impossible, 
or  at  least  injudicious,  to  attempt  it,  because  the  disease  has  advanced 
too  far.  Naturally  different  operators  hold  different  views  as  to  when 
a  case  is  operable  and  when  inoperable. 

This  is  not  the  place  to  discuss  this  important  question  of 
*  operability  '  in  carcinoma  of  the  cervix.  All  I  wish  to  point  out  is 
that,  no  matter  upon  what  ground  one  bases  one's  decision  as  to 
whether  a  case  is  operable  or  not,  it  will  be  found  that  there  are 
more  operable  cases  amongst  the  pregnant  than  amongst  the  non- 
pregnant. 

Such  a  state  of  matters  is  highly  satisfactory,  and,  if  one  thinks  of 
it,  it  is  not  surprising.  Advanced  carcinoma  must  be  a  hindrance  to 
conception,  and,  consequently,  one  encounters  it  in  the  pregnant 
•comparatively  seldom.  More  important,  however,  than  that  is  the 
fact  that,  if  a  woman  the  subject  of  carcinoma  becomes  pregnant, 
the  haemorrhage  causes  her  to  seek  advice  early,  for  she  is  well  aware 
of  the  danger  of  haemorrhage  in  pregnancy.  Lastly,  there  is  the 
labour  which  she  is  bound  to  go  through,  and  which  compels  her  to 
submit  to  a  vaginal  examination,  and  this  gives  her  medical  attendant 
the  opportunity  of  recognizing  any  tumour. 

In  discussing  the  treatment  of  carcinoma  of  the  cervix  in  the 
pregnant  or  parturient,  we  shall  first  consider  those  cases  in  which  the 
•disease  is  not  too  far  advanced  for  removal,  and  later  those  where  the 
•disease  is  inoperable. 

Cases  of  Carcinoma  of  the  Cervix  complicating'  Pregnancy  and 
Labour  in  which  the  Disease  is  not  too  far  advanced  for 
Removal. 

One  would  think  that  it  would  be  admitted  by  all  that  whenever  a 
carcinoma  of  the  cervix  is  recognized,  be  it  early  or  late  in  pregnancy, 
the  uterus  should  be  at  once  removed.  Yet  there  are  a  few  French 
obstetricians — Pinard,1  the  late  Varnier,  Bouilly,  and  others — who 
question  the  advisability  of  immediate  operation  in  the  later  months 
of  pregnancy,  and  advocate  instead  delaying  the  operation  in  the 
interests  of  the  child.  Such  an  attitude  towards  operable  carcinoma 
•cervicis  in  pregnancy  has  been  generally  condemned,  and  by  none 
more  strongly  than  by  Pinard's  own  countrymen,  R.  and  A.  Con- 
damin2  and  Pollosson.3 

Almost  all  are  agreed,  then,  that  the  condition  must  be  dealt  with 
immediately  it   is   recognized,  and  most   approve   of   removing  the 

1  Annul  cle  Gyn.,  1901.  2  Ibid.,  March,  1905,  p.  129. 

:5  Ibid.,  August,  1905,  p.  479. 


218  OPERATH  B   MIDYVI  l-Kl;Y 

diseased  uterus  along  with  the  ovaries.  The  induction  of  premature 
labour  or,  if  the  pregnancy  has  only  advanced  to  the  earlier  weeks, 

the  induction  of  abortion  prior  to  removing  the  uterus  has  nothing 
in  its  Favour.  By  adopting  such  a  course  one  adds  to  the  subsequent 
danger  of  the  hysterectomy,  which  must  ultimately  be  undertaken,  all 
the  immediate  dangers  of  septic  infection  following  the  emptying  of 
the  uterus. 

In  addition,  all  operators,  with  only  one  exception,  as  far  as  I  am 
aware,  recommend  the  removal  of  the  whole  uterus.  The  exception  is 
Spencer.1  The  cases  of  Spencer  are  certainly  interesting,  but  all 
operators  who  have  lived  through  the  time  when  high  amputation  of 
the  cervix  was  practised  could  give  similar  experiences,  if  not  in 
connexion  with  carcinoma  of  the  gravid  uterus,  at  least  in  connexion 
with  the  non-gravid.  Would  not  an  equally  good  result  have  followed 
hysterectomy  in  these  cases?  Spencer's  answer  is  that  it  has  not 
done  so  in  the  past,  and  he  mentions  how  few  permanent  cures  have 
followed  ;  indeed,  he  was  able  to  find  only  two  cases.  E.  and  A.  Con- 
damin,  however,  have  collected  quite  a  number  of  cases  operated  upon 
in  pregnancy,  eight  of  them  late  in  pregnancy  or  after  labour,  and  to 
which  the  term  '  cure  '  may  be  rightly  applied,  for  it  is  four  or  more 
years  since  the  operation  ;  besides,  they  mention  several  in  which 
there  is  a  good  prospect  of  the  cure  being  permanent.  It  appears  to 
me  unfortunate  at  this  juncture,  when  the  whole  tendency  is  to  favour 
radical  measures  in  dealing  with  carcinoma,  that  this  old  treatment 
of  high  amputation  should  be  revived.  Without  doubt,  occasional 
successes  will  follow  such  treatment,  but  how  is  one  to  decide  in  a 
particular  case  when  it  should  be  employed  and  when  hysterectomy  is 
necessary?  With  our  present  knowledge  of  carcinoma  of  the  cervix, 
be  it  in  the  pregnant  or  the  non-pregnant,  the  only  course  is  to  remove 
the  uterus  and  cellular  tissue  as  early  as  possible,  and  to  err  rather  on 
the  side  of  operating  too  often.  Whenever  there  is  the  least  prospect 
of  removing  the  uterus  and  tumour,  an  attempt  should  be  made  to  do 
so,  for,  without  doubt,  occasional  permanent  cures  follow  even  in 
apparently  hopeless  cases. 

In  dealing  with  carcinoma  of  the  cervix  in  the  pregnant  or  par- 
turient, if  one  were  to  judge  by  current  literature,  the  vaginal  route 
is  very  much  in  favour.  This  is  all  the  more  striking  when  so  many 
advocate  the  abdominal  route  for  the  condition  in  the  non-gravid.  The 
explanation,  however,  is  simple.  In  recent  years,  since  it  has  come  to 
be  appreciated  that  the  gravid  uterus  even  of  four  months  and  the  post- 
partum uterus  at  term  can  be  removed  without  difficulty  per  vaginam, 
it  has  become,  for  the  time  being,  fashionable  to  adopt  the  vaginal 
1  Trans.  London  Obst.  Sue,  1905,  vol.  xlvi..  p.  :S.V>. 


CARCINOMA  OF  THE  CERVIX  219 

route.  There  is  evidence  already  that  a  reaction  has  set  in.  Sooner 
or  later  the  abdominal  route  will  be  employed  for  all  cases,  both  gravid 
and  non-gravid. 

In  the  early  months  of  pregnancy — indeed,  up  to  about  the  end  of 
the  fourth — the  ovum  and  uterus  may  be  removed  per  vaginam  entire. 
If  the  pregnancy  has  advanced  beyond  the  fourth  month,  the  uterus 
must  first  be  emptied  if  it  is  to  be  removed  by  the  vagina.  Vaginal 
Cesarean  section,  followed  by  vaginal  hysterectomy,  is  not  to  my 
mind  a  wise  procedure.     I  believe  the  abdominal  route  is  the  best. 

In  operable  cases  where  the  pregnancy  has  advanced  beyond  the 
early  months  or  the  patient  is  in  labour,  the  following  are  the  alterna- 
tive procedures.  They  indicate  the  evolution  of  operative  treatment 
for  this  condition,  and  consequently  I  consider  them  in  detail. 

(1)  Cesarean  section  followed  by  supravaginal  amputation  of  the 
uterus,  with  subsequent  removal  of  the  vaginal  stump  per  vaginam. 
(2)  Cesarean  section,  ligation  and  division  of  the  ovarian  and  uterine 
vessels  and  other  connexions,  with  removal  of  the  whole  uterus  per 
vaginam.  (3)  Vaginal  Cesarean  section  followed  by  vaginal  hysterec- 
tomy.    (4)  Csesarean  section  followed  by  abdominal  hysterectomy. 

Naturally,  in  all  cases  prior  to  proceeding  to  the  removal  of  the 
uterus,  the  malignant  mass  is  thoroughly  scraped  and  the  vagina 
disinfected. 

(1)  Csesarean  Section  followed  by  Supravaginal  Amputation  of 
the  Uterus,  with  Subsequent  Removal  of  the  Vaginal  Stump  per 
Vaginam. — This  method  was  recommended  by  Zweifel.  It  possesses 
all  the  advantages  of  the  abdominal  route,  and  at  the  same  time 
removes  any  risk  of  septic  infection,  as  there  is  no  dragging  of  the 
tumour  through  the  abdomen.  There  is  sometimes,  however,  some 
difficulty  in  removing  the  stump  per  vaginam  if  the  disease  has 
destroyed  the  cervix,  and  so  the  method  is  not  much  favoured.  The 
same  operation,  only  performed  the  reverse  way — namely,  the  removal 
of  the  cervix  per  vaginam,  and  then  attacking  the  uterus  from  the 
abdomen — has  also  been  sometimes  employed.  It,  however,  possesses 
even  greater  disadvantages.  Although  I  adopted  the  latter  variation 
in  one  case,  I  do  not  favour  either. 

(2)  Csesarean  Section,  Lig-ation  and  Division  of  the  Ovarian 
and  Uterine  Vessels  and  Other  Connexions,  with  Removal 
of  the  Whole  Uterus  per  Vaginam. — This  method  is  specially 
associated  with  the  name  of  Olshausen.  It  was  devised  with  the 
object  of  getting  over  the  danger  of  bringing  up  the  septic  cervix 
through  the  abdomen.  I  have  upon  one  occasion  employed  this  method, 
and  was  very  satisfied  with  it.  The  uterus  was  readily  removed, 
even  although  in  the  particular  case  I  mention  the  pregnancy  had 


220  OPERATIVE  MIDWIPERI 

reached  term.  I  am  inclined  to  think,  however,  that  the  method  is 
unnecessarily  complicated  as  compared  with  the  most  modern  method 
of  performing  the  operation  from  the  abdomen,  described  under 
Method  (4). 

(8)  Vaginal  Caesarean  Section  followed  by  Vaginal  Hysterec- 
tomy.— This  is  the  most  recent  method,  and  is  specially  associated 
with  the  name  of  Duhrssen.  Several  operators  in  Germany,  more 
particularly  Bumm  and  Orthmann,  favour  it,  but  it  has  few  supporters 
in  other  countries.  In  Great  Britain,  "Wilson1  of  Birmingham  has 
recently  recorded  two  cases  successfully  operated  upon  at  the  eighth 
month.  Orthmann  puts  the  mortality  at  17  per  cent.  The  method 
of  performing  vaginal  Caesarean  section  is  described  in  Chapter  WYIII. 

Although  I  have  no  experience  of  the  operation  for  malignant 
disease,  I  have  found  it  useful  in  other  conditions.  Personally,  I  am 
not  in  favour  of  the  method  for  the  condition  we  are  considering,  and 
Wilson  informs  me  that  he  has  now  abandoned  it. 

(4)  Caesarean  Section  followed  by  Abdominal  Hysterectomy. — 
This  is  the  treatment  most  favoured.  It  was  employed  before  the 
other  methods  were  devised,  but  the  results  were  then  very  unsatis- 
factory. The  explanation  given  for  this  was  that  in  pulling  up  the 
septic  cervix  the  peritoneal  cavity  was  infected.  With  more  careful 
technique — packing  off  the  intestines,  carefully  clumping  off  the 
vagina,  and  removing  a  good  portion  of  the  vaginal  wall  along  with 
the  uterus,  much  better  results  have  been  obtained.  In  the  last  few- 
years  the  more  extensive  Wertheim  operation  has  been  employed 
and  recommended.  An  interesting  contribution  to  this  subject  was 
recently  made  by  Cuthbert  Lockyer.2  He  points  out  how  easity  the 
uterus  can  be  removed  owing  to  the  looseness  of  the  connective  tissue. 

Cases  in  which  the  Disease  is  too  far  advanced  for  Removal. 

Naturally,  the  treatment  to  be  adopted  in  this  class  of  case  will 
depend  upon  how  far  pregnancy  has  advanced.  When  the  disease 
is  discovered  in  the  early  months,  the  child  is  the  one  to  be 
considered ;  the  mother's  sufferings  must  be  relieved,  but  the 
pregnancy  allowed  to  continue.  It  may  be  urged  that  this  is  some- 
times rather  cruel  to  the  woman,  and  I  quite  agree,  so  that  had  I  a 
case  in  which  I  believed  the  woman's  sufferings  were  extreme,  and 
that  they  could  only  be  relieved  by  emptying  the  uterus,  I  would  do 
so.  In  none  of  our  cases  in  hospital,  however,  has  this  been 
necessary.  In  none  did  the  mothers  suffer  unduly  during  pregnancy, 
and  in  all  they  carried  the  child  to  near  term,  and  were  operated 
upon  as  I  shall  describe. 
1  Lond.  Obst.  Trans.,  vol.  xlvi.,  p.  378.  -  Brit.  Med.  Journ.,  October  9.  1909. 


CARCINOMA  OF  THE  CERVIX  221 

When  it  comes  to  the  time,  either  at  term  or  earlier,  when  it  is 
deemed  necessary  to  empty  the  uterus,  the  best  method  to  pursue  is 
to  do  Cesarean  section  and  then  perform  supravaginal  hysterectomy. 
Hysterectomy  is  performed  because  of  the  danger  of  the  puerperal 
uterus  being  infected  from  the  septic  cervix.  It  is  thus  evident  that 
it  is  a  distinct  advantage  to  operate  before  labour  has  commenced, 
while  the  cervix  is  still  closed.  The  stump,  after  removal  of  the 
uterus,  may  be  treated  either  intra-  or  extra-peritoneally.  Few 
recommend  the  latter,  although  Spencer  in  this  country  and  Fehling 
in  Germany  do  so.  The  object  in  treating  the  stump  extraperitoneally 
is  to  shut  off  the  cervical  canal  from  the  abdominal  cavity.  In  the 
cases  operated  upon  in  the  Glasgow  Maternity  Hospital  the  cervical 
stumps  were  treated  intraperitoneally.  The  women  were  delivered  of 
living  children,  and  recovered  without  any  complications.  The}7  died 
five  to  seven  months  later. 

In  the  cases  which  come  under  one's  notice  for  the  first  time 
during  labour,  the  malignant  mass  should  not  be  scraped  and 
cauterized  as  is  the  general  procedure  in  operating  upon  the  non- 
gravid.  The  uterus  should  be  removed  by  supravaginal  amputation. 
As  an  alternative  to  such  treatment,  the  labour  may  be  allowed  to 
pursue  its  natural  course.  The  dangers  of  so  doing  are  severe 
haemorrhage,  rupture  of  uterus,  and  sepsis.  Examples  of  each  of 
these  complications  will  be  found  recorded.  It  must  be  admitted, 
however,  that  a  very  large  proportion  of  the  cases  escape  the  com- 
plications mentioned. 

Before  leaving  the  subject  I  would  just  say  that  inoperable  cases 
should  always  be  examined  a  week  or  ten  days  after  delivery.  One  or 
two  writers  have  referred  to  the  fact  that  these  growths  often  assume 
a  more  hopeful  appearance  as  the  uterus  diminishes  in  size. 


CHAPTEB   XV 

DYSTOCIA  THE  RESULT  OF  ABNORMALITIES  AFFECTING  THE 
PARTURIENT  CANAL— Continued 

Tumours  of  the  Ovary. 

Tumours  of  the  ovary  are  such  a  common  occurrence  that  it  is  not  to 
be  wondered  at  that  they  should  be  encountered  now  and  again  in  the 
pregnant  and  parturient.  My  records  show  a  frequency  of  about  1  in 
1,500.  It  must  be  remembered,  however,  that  those  engaged  as 
specialists  have  many  more  opportunities  for  encountering  the  com- 
plication than  the  general  practitioner,  so  that  statistics  based  on 
hospital  records  or  the  private  practice  of  obstetric  specialists  give  no 
correct  idea  of  the  frequency  of  the  complication. 

All  the  different  varieties  of  ovarian  growths  may  be  found. 

In  the  862  cases  collected  by  McKerron1  the  following  were 
found : 

Simple  and  multilocular  cysts  (a  few  papillomatous)  ...  594=68  per  cent. 

Dermoids                 ...             ...             ...             ...  ...  204=28         ,, 

Fibromata  or  solid  adenomata             ...             ...  ...       19=  2         ,,. 

Malignant  (carcinomatous  or  sarcomatous)       ...  ...  45=   5 

862 

Spencer2  made  an  important  contribution  to  the  subject  last  year, 
and  Marshall's3  recently  published  paper  contains  many  interesting 
cases  and  a  very  full  bibliography. 

The  tumours  are  of  all  shapes  and  sizes,  but  in  a  very  large 
proportion  of  cases  they  are  small,  and  occupy  the  pelvic  cavity. 

There  seems  to  be  some  difference  of  opinion  as  to  whether  or  not 
ovarian  tumours  increase  in  size  during  pregnancy.  Olshausen  and 
Schauta  believe  they  do,  but  Lohlein  and  Williams  have  denied  this. 
I  can  give  no  personal  experience,  as  I  have  never  had  cases  under 
observation  before  and  during  pregnancy.  I  have  always  removed  the 
tumour  whenever  I  have  recognized  it. 

1  •  I'regnancy,  Labour,  and  Childbed,  with  Ovarian  Tumours,'  1903. 

2  Surgery,  Gynecology  and  Obstetrics,  May,  1909. 

3  Journ.  Obst.  and  Gyn.  Brit.  Empire,  February,  1910. 

222 


TUMOURS  OF  THE  OVARY  223 

Pregnancy  associated  with  ovarian  tumours  is  usually  but  little 
disturbed  :  and  if  any  discomforts  arise,  they  are,  as  a  rule,  of  so  slight 
a  nature  as  to  escape  recognition  altogether,  both  the  patient  and 
doctor  attributing  them  to  the  ordinary  disturbances  of  pregnancy. 
In  only  five  of  my  eighteen  cases  was  the  condition  appreciated 
during  pregnancy.  McKerron  writes  of  the  cases  which  come  under 
observation  :  '  In  over  80  per  cent,  no  suspicion  of  its  existence  was 
entertained  till  its  presence  was  revealed  by  vaginal  examination  in 
the  course  of  delivery.' 

Occasionally,  during  pregnancy,  some  pain  is  complained  of,  and 
not  infrequently  disturbance  of  urination.  This  latter  symptom  was 
markedly  present  in  a  case  of  sacculation  of  the  gravid  uterus  caused 
by  a  broad  ligament  cyst,  fully  detailed  on  p.  285.  Again,  reflex 
phenomena,  such  as  morning  sickness,  are  sometimes  very  much 
exaggerated,  as  I  saw  in  a  case  of  lateral  flexion  of  the  gravid  uterus 
caused  by  a  small  dermoid.  It  occasionally  happens  that  the  great 
size  of  the  abdomen,  especially  if  it  does  not  correspond  to  the  age  of 
the  pregnancy,  causes  disturbance  in  the  respiratory  and  circulatory 
systems,  and  arrests  attention ;  but  these  symptoms  are  much  more 
frequent  with  myomata. 

Should,  however,  any  of  the  accidents  to  which  ovarian  tumours 
are  liable  occur,  attention  is  at  once  directed  to  the  abdomen,  and 
there  is  every  chance  of  the  condition  being  recognized.  The  most 
common  accidents  are  rupture,  torsion  of  the  pedicle,  incarceration, 
suppuration,  and  necrosis. 

I  have  not  seen  torsion  of  the  pedicle  during  pregnancy,  but  in 
two  of  my  cases  it  occurred  immediately  after  delivery.  McKerron 
states  that  in  his  collected  cases  it  occurred  in  12  per  cent,  during 
pregnancy,  and  in  as  many  as  20  per  cent,  during  the  puerperium. 
He  puts  the  condition  apart  from  pregnancy  at  8  per  cent.,  a  figure 
that  exactly  agrees  with  my  own  experience.1  It  is  therefore  evident 
that  the  accident  is  very  much  more  frequent  in  the  pregnant,  and 
especially  in  the  puerperal,  condition.  I  am  surprised,  however,  that 
McKerron  has  found  it  so  common  during  pregnancy.  One  knows 
that  it  is  very  common  during  the  puerperium,  but  I  hardly  thought  it 
was  as  frequent  as  12  per  cent,  in  pregnancy.  The  symptoms  of  the 
accident  are  quite  distinct  if  the  torsion  is  acute — sudden  and  severe 
abdominal  pain,  with  collapse  more  or  less  profound,  distension  and 
tenderness  of  the  abdomen,  and,  if  the  tumour  is  palpable,  increase 
of  its  size.  When  the  torsion  is  more  gradual,  the  pain  and  other 
symptoms  are  less  severe. 

1  'Complications  and  Difficulties  in  a  Series  of  250  Ovariotomies/  Journ. 
Obst.  and  Gijn.  Brit.  Empire,  September,  1909. 


224  OPERATIVE   MIDWIKKKY 

I  have  only  once  encountered  rupture  of  a  cyst  associated  with 
pregnancy — viz.,  when  removing  a  dead  ovum  in  a  case  of  abortion. 
The  patient  complained  only  of  a  little  abdominal  pain,  and  there  was 
a  slight  rise  of  temperature  and  pulse.  On  opening  the  abdomen 
a  few  days  later,  the  collapsed  cyst  was  removed.  McKerron  puts  the 
frequency  at  2*8  per  cent.,  but  the  older  writers  put  it  usually  at 
double  that  figure.     During  labour  it  occurs  in  about  IB  per  cent. 

As  regards  suppuration,  it  is  very  rare  indeed  during  pregnancy, 
and  it  is  often  a  question  if  the  pregnant  condition  has  had  anything 
to  do  with  it.  The  more  likely  explanation  is  that  the  tumours  become 
infected  quite  independently  of  the  gravid  state,  or  that  the  condition 
existed  before  the  pregnancy.  On  the  other  hand,  suppuration  readily 
occurs  in  the  puerperium  if  there  is  any  infection  of  the  parturient  canal 
during  parturition.   Dermoid  tumours  are  specially  liable  to  be  infected. 

Necrosis  of  the  tumour  is  likewise  not  uncommon,  especially  during 
the  puerperium.  It  results  from  injuries  inflicted  b}r  pressure,  as  in 
the  very  striking  example  of  the  accident  recorded  later  (p.  232). 

A  veiy  rare  accident  is  the  forcing  of  the  tumour  down  between 
the  uterus  and  the  vagina,  and  the  final  expulsion  of  the  tumour 
per  rectum  or  per  vaginam.  McKerron  has  collected  thirteen  cases. 
Walls,1  Sutton,-  and  Haultain3have  recorded  cases.  In  most  of  them 
the  accident  occurred  during  forcible  extraction  with  forceps,  but  in 
one  or  two  it  occurred  during  spontaneous  delivery.  In  a  considerable 
number,  especially  the  earlier  cases,  death  resulted. 

Another  accident  which  has  occurred  in  a  few  cases  is  rupture  of 
the  uterus. 

The  diagnosis  of  ovarian  tumours  in  pregnancy  is  usually  not 
difficult.  It  is  e&sy  when  the  tumour  is  in  the  pelvis  (Fig.  L20) 
and  the  pregnancy  is  not  far  advanced,  for  then  one  can  by  bi- 
manual palpation  differentiate  the  enlarged  uterus  and  the  tumour. 
Also  during  labour  it  is  not  difficult,  for  the  tumour  in  the  pelvis 
can  be  readily  felt  obstructing  the  parturient  canal.  Even  when 
pregnancy  has  advanced  to  the  later  months,  with  the  tumour  above 
the  brim,  it  is  not  difficult,  provided  the  swelling  is  of  some  size. 
But  if,  as  in  two  cases  which  were  under  my  care,  the  tumour  is  placed 
behind  the  uterus  to  one  or  other  side  of  the  vertebral  column,  it  may 
be  impossible  to  reach  it.  In  one  of  these  (Fig.  121)  I  could  only  feel 
high  up  above  the  brim  an  indefinite  fullness.  I  could  not,  even 
under  an  anaesthetic,  get  any  tumour  between  nry  hands.  In  the 
other  case  the  tumour  was  not  recognized  until  after  delivery. 

Almost  invariably — and  this  is  a  feature  of  great  importance — the 

1   Brit.  M<;1.  Journ.,  February  3,  1900. 

-'  Lancet,  February  9,  1901.  :1  Tbid.,  January,  190*2. 


TUMOURS  OF  THE  OVARY 


225 


position  of  the  cervix  is  altered,  and  most  commonly  it  is  displaced 
forwards  and  to  one   side.     If  the  tumour  is  large,  it  may  also  be 


FlG.   120. — Ovarian  Cyst  entirely  in  the  Pelvis.     (Author's  Collection.) 

This  tumour  was  pushed  out  of  the  pelvis  in  the  second  stage  of  labour,  and  the  child 
extracted  with  forceps.  The  tumour  was  removed  three  weeks  after  the  confinement 
by  abdominal  section. 

displaced  upwards,  although  that  is  a  much  more  common  feature  of 
myomatous  growths. 

So  far  I  have   been   considering   the   cases  where  pregnancy  is 
a  certainty,  but  the  tumour   is   doubtful.      Before    the    uterus  has 


226 


OPERATIVE  Mll>\\il  T.liY 


increased  in  size,  it  is  often  difficult  to  make  sure  of  pregnan 
with  the  pelvic  organs  in  a  normal  condition.     Much  more  is  this  tin- 
case  with  an  ovarian  tumour  above  the  brim.    The  objective  symptoms 


Fig.   121.  —  Ovarian  Cyst  which  in  Part  projected  into  the  Pelvis.     (Author's  Oolle  stion. 

This  tumour  was  removed  by  abdominal  section  during  labour,  the  child  being  afterwards 

extracted  with  forceps. 

of  pregnancy,  however,  the  changes  in  the  hreasts  and  cervix,  and, 
above  all,  a  steady  increase  in  the  size  of  the  uterus,  are  the  indications 


ITMOURS  OF  THE  OVARY  227 

one  relies  upon.  In  this  connexion,  it  must  not  be  forgotten  that  the 
subjective  symptom  of  suppression  of  menstruation  is  by  no  means  an 
uncommon  feature  of  ovarian  cystomata,  quite  apart  from  pregnancy. 

Even  with  a  tumour  in  the  pelvis  the  differential  diagnosis  may 
sometimes  be  difficult.  This  is  seen  in  two  conditions  in  particular 
— retrodisplacement  of  the  gravid  uterus  and  extra-uterine  pregnancy. 
Both  may  simulate  or  be  simulated  by  an  ordinary  uterine  pregnancy 
complicated  by  an  ovarian  cyst.  It  is  rarely,  however,  that  a  careful 
consideration  fails  to  clear  matters  up.  The  absence  of  the  fundus  in 
front  and,  if  the  fundus  is  incarcerated,  as  in  the  case  of  retrodisplace- 
ment, the  difficulty  of  urination,  make  the  diagnosis  easy.  Softness 
and  immobility  of  the  tumour,  abdominal  pain,  and  irregular  haemor- 
rhages are  the  features  most  to  be  relied  on  in  the  case  of  extra- 
uterine pregnancy. 

The  prognosis  when  pregnancy  or  labour  is  complicated  by 
ovarian  tumours  is  very  different  to-day  as  compared  to  twenty  or 
thirty  years  ago.  The  reason  for  this  is  obvious.  Removal  of  the 
tumour  during  pregnancy  has  been  substituted  for  expectancy,  and 
displacement  or  removal  during  labour  has  been  substituted  for 
dragging  the  child  past  the  obstruction  with  forceps  or  by  traction  on 
its  legs. 

It  is  now  generally  accepted  that  when  an  ovarian  tumour  is 
discovered  during  pregnancy  it  should  be  removed  at  once,  and  this 
no  matter  what  the  size,  nature,  and  position  of  the  tumour  may 
be.  The  extremely  good  results  following  abdominal  section  during 
pregnancy  justify  this  decided  attitude.  McKerron,  from  his  analysis 
of  480  cases,  found  a  maternal  mortality  of  only  5  per  cent.  In 
many  of  these  cases,  moreover,  the  injury  which  the  tumour  had 
undergone,  and  the  general  condition  of  the  patient  at  the  time 
of  the  operation,  were  really  responsible  for  the  death.  He  writes  : 
'During  the  last  twelve  years  no  fewer  than  299  ovarian  tumours 
during  pregnancy  have  been  recorded.  Although  in  many  of  these 
acute  symptoms  existed  at  the  time  of  operation,  only  ten  of  the 
patients  died,  or  a  mortality  of  3*3  per  cent.' 

My  own  experience  is  in  entire  agreement  with  these  figures,  for 
on  the  few  occasions  upon  which  I  have  operated  all  the  patients 
made  uninterrupted  recoveries.  On  one  occasion  the  operation  was  of 
extreme  difficulty,  for  the  cyst  was  a  broad-ligament  one  which  had 
burrowed  away  down  into  the  cellular  tissue  behind  the  rectum. 

But  the  results  are  most  satisfactory  from  another  standpoint— 
viz.,  pregnancy  in  a  very  considerable  number  of  cases  is  not 
disturbed.  As  regards  my  own  six  cases,  two  were  aborting  at 
the  time  they  were  placed  under  my  care;  in  the  other  four  the 


228 


OPERATIVE  MIDWIFERY 


pregnancy  continued  undisturbed,  liven  in  the  ease  quoted  in  which 
I  removed  the  cyst  from  the  broad  ligament  in  the  fourth  month  the 
pregnancy  continued  undisturbed.  Curiously  enough,  of  the  recorded 
cases  of  removal  of  intraligamentary  cysts  during  pregnancy,  in  very 
few  has  the  pregnancy  been  disturbed.  There  are  comparatively  few 
cases  recorded  :  but  it  stands  to  reason  that  the  more  difficult  the 
operation,  and  the  more  extended  the  handling  of  the  cyst  and  the 
abdominal  and  pelvic  organs,  the  more  likely  will  labour  be  induced. 
As  far  as  can  be  judged,  the  pregnancy  is  less  likely  to  be  disturbed 
when  the  operation  is  performed  in  the  early  months,  as  can  be  seen 
from  Mclverron's  table  : 1 


Total  Cases. 

Kccent  Cases. 

M"llth  of 
Pregnancy. 

Number  of 
i  Operations. 

Pregnancy  inter- 
rupted and  Child 

lost: 

Number  of 
Operations. 

incy  interrupted  and  Child  lost. 

All  Cases. 

Excluding  Compli- 
cated 1 

Second. 

Third. 

Fourth. 

Fifth. 

Sixth. 

Seventh. 

Eighth. 

Ninth. 

39 
102 
84 
55 
22 
23 
14 
7 

10  =  25-6 
19  =  18-6 
12  =  14-2 
14  =  25-4 

11  =  34-3 
9  =  39-1 
6  =  42-8 
1  =  14-2 

28 
60 
60 
38 
22 
15 
7 
6 

6=20-7 

9  =  15 

7  =  11-6 

8  =  21 
8  =  36 
5  =  33 
4  =  57 
0=   0 

5=185 

5=    -  - 
3=   5-3 
2=  6-2 
4=22-2 

3  =  200 

4  =  57-1 
0=   0 

Michin2  gives  for  ten  cases  in  the  Maternity  Department  of  the 
University  of  Charkow  100  per  cent,  maternal  recovery  and  i)0  per  cent, 
pregnancy  uninterrupted.  These  figures  correspond  very  closely  to 
the  latest  statistics  of  Graefe.:!  The  latter  author  finds  that  in  215  cases 
performed  since  li)02  the  maternal  mortality  was  only  0'47  per  cent., 
and  the  cases  where  labour  was  induced  only  16  per  cent. 

With  results  so  good  for  mother  and  child,  is  an  expectant  attitude 
ever  justifiable?  As  regards  tumours  recognized  early  in  pregnancy, 
it  must  be  a  very  rare  case  indeed  in  which  one  is  justified  in 
leaving  matters  to  Nature,  for  early  in  pregnancy,  the  uterus  being 
small,  the  cyst  can  be  removed  without  difficulty,  and  with  a  com- 
paratively small  abdominal  incision.  On  the  other  hand,  late  in 
pregnancy,  seeing  that  labour  is  more  frequently  induced,  one  may  be 
justified  in  delaying  operation  for  the  sake  of  the  child  until  shortly 
before  term,  when  it  matters  little  whether  labour  comes  on  or  not. 

1  Op.  cit.    p.  114.  2  Kef.  Zcnt.f.  Gytl.,  1903,  p.  318. 

3  Zcit.  f.   Geb.  u  Gyn..  1  Jd .  hi.,  Heft  3;  ref.  Joitrn.  Obst.  and  Gfyn.,  October, 
1906. 


TUMOURS  OF  THE  OVARY  22!) 

If  such  a  course  is  decided  upon,  the  patient  should  be  kept  under 
most  careful  observation.  There  is,  however,  one  great  objection  to 
this  course.  Not  infrequently  ovariotomy  late  in  pregnancy  and 
during  labour  is  rendered  difficult  by  reason  of  the  size  of  the  uterus. 
Without  doubt  this  difficulty  may  be  overcome  by  bringing  the  uterus 
out  of  the  abdomen,  and  replacing  it  after  removing  the  tumour,  but 
such  a  step  is  naturally  undesirable,  as  it  involves  making  a  very 
long  abdominal  incision. 

But  if  the  treatment  to  be  adopted  with  ovarian  tumours  during 
pregnancy  is  self-evident,  it  is  very  different  when  these  growths  are 
discovered  and  have  to  be  dealt  with  during  labour.  It  is  useless  to 
say  that  abdominal  or  vaginal  cceliotomy  should  always  be  performed, 
for  that  is  not  practicable.  How  could  a  country  practitioner,  for 
example,  perform  abdominal  section  in  a  farmhouse,  many  miles  from 
his  home,  without  appliances  or  assistants  ?  Yet  any  practitioner  in 
the  country  may  be  placed  in  such  a  position,  and,  as  a  matter  of 
fact,  a  friend  of  mine  had  exactly  such  an  experience.  It  is  perfectly 
apparent,  therefore,  that  the  treatment  to  be  adopted  depends  largely 
upon  whether  or  not  one  is  within  easy  access  of  a  hospital  or  nursing 
home,  or  can  get  assistants  and  appliances  at  short  notice. 

Without  doubt,  theoretically,  the  ideal  treatment  is  to  remove  the 
tumour  by  the  abdomen  or  the  vagina,  and  then  to  remove  the  child 
per  vias  naturales.     Here  is  an  example  of  this  treatment : 

One  morning,  four  years  ago,  I  was  asked  by  Dr.  J.  Wright,  of 
Glasgow,  to  see  a  multipara,  about  eight  months  pregnant,  who  had 
been  many  hours  in  labour.  The  cause  of  the  delay,  he  believed,  was 
an  abdominal  tumour.  When  I  examined  her,  I  found  labour  was 
well  advanced,  but  the  head  was  prevented  from  entering  the  brim  by 
reason  of  a  tumour,  the  lower  margin  of  which  could  be  felt  project- 
ing over  the  pelvic  brim.  This  was  even  more  clearly  made  out  after 
emptying  the  bladder.  She  was  removed  to  the  Maternity  Hospital, 
where  I  performed  laparotomy.  There  was  some  little  difficulty  in 
reaching  the  tumour,  but  that  was  ultimately  accomplished  by  turn- 
ing the  uterus  out  of  the  abdomen.  After  removing  the  tumour,  the 
uterus  was  replaced.  The  delivery  of  the  child  was  completed  by 
forceps. 

Considerable  difficulty  has  been  experienced  in  some  cases  in 
getting  the  tumour  up  out  of  the  pelvis.  In  such  cases  it  is  often 
sufficient  to  turn  out  the  uterus  and  then  bring  up  the  tumour  ;  but 
in  a  certain  number,  even  when  the  abdomen  is  opened,  and  even 
after  the  uterus  has  been  turned  out,  it  is  not  possible  to  remove 
the  tumour.  In  such,  the  only  course  open  is  to  perform  Cesarean 
section,  extract  the  child,  and  then  deal  with  the   tumour.      That 


230  OPERATIC  E  MIDWIFERY 

Buch   a    treatment  is  occasionally  necessary  is  quite  certain,  and  it 
is   absurd   for   30me   writers    to    say  that    Cesarean    Bection  is   in 
necessary. 

What  might  be  done  in  the  case  of  broad-ligament  cysts  is  simple 
puncture  from  the  vagina,  for  one  knows  that  such  a  treatment  cu 
many  of  these  cysts.  Couvelaire1  actually  did  this,  and  delivered 
the  child  per  vaginam,  and  found,  some  years  later,  no  trace  of  any 
tumour.  Even  if  one  did  not  diagnose  the  exact  condition  until  the 
abdomen  was  opened,  it  might  be  quite  sound  treatment,  instead  of 
trying  to  enucleate  the  cyst,  to  tap  it  from  below. 

Good  results  have  also  been  obtained  from  vaginal  ovariotomy 
during  labour.  The  cases  which  are  suitable  for  this  treatment  are 
small  tumours  low  down  in  the  pouch  of  Douglas,  so  that  one  can 
be  sure  of  getting  a  pedicle  long  enough  to  allow  of  a  ligature  being 
applied.  I  have  thrice  had  experience  of  this  operation — twice  for  an 
ovarian  tumour  and  once  for  a  pedunculated  myoma  which  bulged 
down  into  the  vagina.  I  had  no  difficulty  in  removing  the  tumour 
first,  and  then  the  child,  and  finally  stitching  up  the  vaginal  incision. 
In  the  case  of  the  myoma,  when  tying  the  pedicle,  the  latter  gave  way, 
but  as  the  tumour  was  a  myoma,  I  did  not  think  it  necessary  to  open 
the  abdomen,  for  the  gauze  which  I  pushed  into  the  pouch  of  Douglas, 
uhen  removed  after  the  birth  of  the  child,  was  quite  dry.  There  had 
been  no  bleeding.  Ranch2  has  recorded  a  similar  accident  in  the 
case  of  vaginal  ovariotomy.  In  that  case — and  this  should  always 
be  done  in  the  case  of  ovarian  tumours — the  abdomen  was  opened 
and  the  pedicle  secured. 

Personally,  I  have  no  great  liking  for  vaginal  celiotomy,  for  in 
the  cases  referred  to  and  in  others  which  I  have  read  of  there  has 
been  some  little  difficulty  in  securing  the  pedicle.  In  theory  the 
operation  is  very  simple.  An  incision  being  made  over  the  tumour, 
and  the  pouch  of  Douglas  opened,  the  tumour  is  pulled  out  through 
the  wound.  The  pedicle  is  then  tied.  In  doing  so  it  is  well  to  pass 
the  ligatures  through  its  tissue,  so  that  when  the  pedicle  is  cut  and 
the  tension  upon  it  removed,  the  ligature  will  not  slip.  After  the 
tumour  has  been  removed,  the  wound  in  the  vault  of  the  vagina  is 
stitched.  No  drainage  is  necessary.  The  child  should  then  be 
extracted  by  forceps,  or  the  delivery  left  to  Nature.  In  some  few 
cases,  to  be  referred  to  later,  the  tumour,  if  it  cannot  be  removed, 
may  be  evacuated  of  its  contents,  provided  it  is  cystic,  secured  by  a 
ligature,  and  removed  after  the  delivery  of  the  child,  when  the  pedicle 
is  relaxed,  owing  to  the  uterus  being  so  much  smaller. 

1  Soc.  d'Obat.  de  Qyn.  et  de  V&A.  dt  Pom,  July,  1902. 
-'    [naug.  I>is..  Leipzig,  190o. 


TUMOURS  OF  THE  OVARY  231 

As  regards  the  results  obtained  from  this  method,  they  are 
fairly  satisfactory.  The  strongest  advocate  of  the  vaginal  route  is 
Duhrssen;1  but  even  he  is  forced  to  admit  that  there  is  sometimes 
difficulty  with  the  pedicle,  and  that  the  patient  must  be  prepared  for 
the  abdominal  operation. 

But,  as  already  stated,  the  ideal  treatment  of  immediate  ovari- 
otomy is  not  always  possible,  as,  for  example,  in  the  two  following 
cases : 

A  patient  was  sent  to  me  by  Dr.  Jackson,  late  of  Sanquhar,  a  few 
months  after  her  confinement,  on  account  of  a  painful  swelling,  which 
could  be  felt  low  down  in  the  left  iliac  fossa.  She  resided  at  a  distant 
farm,  several  miles  from  the  doctor,  who  arrived  when  labour  was 
far  advanced.  On  examination,  he  found  that  the  child's  head  was 
prevented  from  descending  by  reason  of  a  small  ovarian  tumour.  He 
had  only  his  ordinary  obstetric  instruments,  and  had  no  assistant 
beyond  a  neighbour,  who  had  come  in  to  lend  a  hand.  He  tried  to 
displace  the  tumour,  but  failed.  As  he  wrote  to  me,  he  had  therefore 
no  alternative,  as  far  as  he  could  see,  but  to  puncture  the  tumour  and 
deliver  the  child.  This  he  did.  The  woman's  recovery  was  uninter- 
rupted. After  seeing  the  patient,  I  sent  her  into  hospital,  and  was 
present  when  abdominal  section  was  performed.  The  operator  found 
the  tumour  most  intimately  attached  to  the  bowel,  and  he  had  great 
difficulty  in  removing  it.  The  patient  died  of  sepsis  a  few  days  after 
the  operation. 

Late  one  evening  I  was  asked  by  Dr.  Cooper,  of  Dennistoun,  to 
see  a  multipara  whose  labour  was  protracted  on  account  of  a  small 
tumour  which  he  diagnosed  as  being  of  ovarian  origin.  The  os  was 
fully  dilated  and  the  tumour  was  pressed  far  down  by  the  child's 
head.  The  surroundings  being  unsuitable  for  abdominal  section,  we 
decided  to  try  to  displace  the  tumour  from  the  pelvis,  and  extract  the 
child  before  having  recourse  to  vaginal  cceliotomy.  Dr.  Cooper  put 
the  patient  deeply  under  chloroform.  I  only  succeeded  in  dislodging 
the  tumour,  however,  after  I  had  pushed  the  foetal  head  out  of  the 
pelvis.  A  living  child  was  extracted  by  forceps.  Some  weeks  later 
I  removed  the  tumour — a  small  dermoid — by  abdominal  section. 
The  operation  was  very  easy,  and  the  patient  made  an  uninterrupted 
recovery. 

Without  doubt,  when  the  surrounding  conditions  are  not  favour- 
able for  abdominal  or  vaginal  cceliotomy,  the  best  course  to  pursue 
is  to  push  the  tumour  out  of  the  pelvis.  In  doing  this,  it  should 
always  be  remembered  that  it  is  of  great  advantage  to  have  the  patient 
deeply  anaesthetized ;  also,  when  pushing  up  the  tumour,  to  dislodge 

1  Dent.  Med.  Woch.,  October  13  and  20,  1904. 


232  OPERATIVE   MIDWIEEI,^ 

tin'  presenting  part  from  the  pelvis,  as  was  done  in  the  la 
described. 

The  results  obtained  by  this  treatment  show  a  mortality  of  5*7  per 
cent.,  a  mortality  only  slightly  worse  than  those  following  ovariotomy. 

So  far,  the  courses  sketched — viz.,  removal  or  displacement  of  the 
tumour — are  those  which  should  be  followed  if  possible.  When, 
however,  we  come  to  the  last  group  of  cases  in  which  these  forme 
treatment  are  deemed  unsuitable  or  impossible,  we  find  at  once 
differences  of  opinion.  One  thing,  however,  is  certain — that  it  is 
never  justifiable  to  pull  the  child  past  the  obstruction,  either  by 
forceps  or  by  traction  on  the  legs.  Craniotomy  will  help  but  little, 
and  is  not  to  be  considered,  even  if  the  child  is  dead.  The  results 
of  pulling  a  child  past  the  obstruction  are  most  disastrous — the 
maternal  mortality  is  somewhere  about  30  per  cent.  Rapture  of  the 
cyst  or  severe  injury,  with  subsequent  necrosis,  are  the  usual  accidents 
which  follow.  Here  is  a  case  which  illustrates  the  danger  of  this 
treatment : 

A  patient  was  admitted  to  the  Western  Infirmary,  under  my  care, 
four  days  after  a  very  difficult  and  tedious  labour.  She  had  an 
extremely  rapid  pulse,  a  temperature  of  102°  P.,  and  looked  and  felt 
very  ill  indeed.  On  examination,  I  found  a  large  soft  tumour  behind 
the  uterus.  I  was  informed  that  the  delivery  of  the  child,  five  days 
prior  to  the  patient's  admission,  was  accomplished  with  great  difficulty 
by  means  of  forceps,  owing,  the  doctor  said,  to  the  presence  of  a  tumour 
in  the  pouch  of  Douglas.  Two  or  three  days  later  I  performed  abdominal 
section,  and  removed  a  necrotic  multilocular  cyst.  So  necrosed  was 
the  tumour  that  it  broke  in  pieces  as  I  removed  it.  The  woman  died 
the  following  day. 

Brute  force,  in  this  as  in  all  other  obstetric  operations,  may  there- 
fore be  dismissed.  There  remains,  consequently,  only  one  course — to 
puncture  or  to  incise  the  cyst.  It  must  at  once  be  admitted  that  many 
disapprove  entirely  of  this  treatment,  and,  rather  than  have  recourse 
to  it,  advocate  the  removal  of  the  patient  to  a  home  or  hospital,  or 
sending  for  an  obstetric  surgeon,  even  although  such  a  course  involves 
many  hours'  delay.  I  have  great  sympathy  with  such  an  attitude, 
but  I  cannot  quite  agree  to  so  extreme  a  position,  for  1  do  think  there 
are  cases  occasionally  encountered  when  puncture  or  incision  must  be 
resorted  to. 

To  simply  puncture  the  tumour,  unless  it  is  a  broad-ligament  cyst, 
is  undesirable,  for  it  is  a  haphazard  treatment,  and  will  result  almost 
certainly  in  some  of  the  contents  of  the  cyst  escaping  into  the  abdomen  ; 
and  although  the  contents  of  ovarian  cystomata  are  generally  sterile, 
occasionally  they  are  not. 


TUMOUliS  OF  THE  OVAttY  233 

A  better  course  is  the  following : 

The  vaginal  walls  being  held  back  by  retractors,  an  incision  is  made 
over  the  projecting  tumour.  The  bleeding  is  seldom  great,  and  can 
be  easily  controlled.  When  the  peritoneum  is  reached,  it  should  be 
opened  with  scissors.  Two  fingers  are  then  introduced  into  the  pouch 
of  Douglas,  and  the  tumour,  if  possible,  pulled  out.  If  the  pedicle  can 
be  safely  ligated  and  the  tumour  removed,  this  should  be  done.  If  not, 
the  tumour  should  be  freely  incised  and  the  contents  evacuated.  If 
then  a  loop  of  silk  can  be  passed  over  the  collapsed  tumour,  this 
should  be  done,  the  long  ends  being  drawn  outside  the  vagina.  The 
tumour  should  then  be  packed  with  gauze,  and  a  little  strip  of  gauze 
pushed  up  beyond  the  tumour.  By  such  a  device  one  can  keep  the 
tumour  well  against  the  vaginal  incision.  The  child  should  be 
extracted  immediately  if  this  is  possible  ;  if  not,  the  case  should  be  left 
till  the  os  is  sufficiently  dilated.  After  the  child  is  extracted  and  the 
placenta  expelled,  the  lips  of  the  cervix  should  be  grasped  with 
volsellum  forceps,  and  slight  traction  made  on  the  uterus.  The 
ligature  which  is  round  the  ovary  should  then  be  pulled  upon,  and 
pressure  made  on  the  uterus  from  above.  By  these  means  the  ovary 
may  now  be  brought  within  reach,  and  its  pedicle  ligatured  and  tied. 
The  vaginal  wound  should  then  be  closed,  or  a  little  loose  packing  left 
in  for  twenty-four  hours. 

Simpler  than  such  a  procedure  is  the  suggestion  of  Fritsch,  to 
stitch  the  sac  to  the  edges  of  the  vaginal  wound  ;  but  it  is  not  always 
easy  to  pass  sutures  in  the  vagina,  and  the  sac  of  all  ovarian  tumours 
is  very  friable.  I  agree  with  Spencer,  therefore,  that  it  is  better  to 
pack  the  sac  with  gauze. 

At  any  time  in  the  puerperium  one  may  be  called  upon  to  remove 
a  tumour  which  has  been  displaced  or  punctured,  for  complications 
are  very  liable  to  follow  labour.  I  have  had  experience  of,  or  seen 
in  the  practice  of  colleagues,  twisting  of  the  pedicle,  suppuration 
and  necrosis,  adhesions  to  the  bowel,  and  even  obstruction  of  the 
bowel. 

I  have  already  detailed  a  case  in  which  necrosis  followed.  Here 
is  one  in  which  the  pedicle  became  twisted : 

Mrs.  A ,   multipara,  was  admitted  to  the  Western  Infirmary, 

under  my  care,  in  September,  1906.  She  was  in  an  extremely 
collapsed  condition  ;  the  pulse  could  hardly  be  counted,  and  she  had 
a  temperature  of  101°  F.  Her  abdomen  was  greatly  distended  and 
very  tender.  The  history  obtained  from  her  medical  practitioner  was 
to  the  effect  that  ten  days  previously  she  had  been  delivered  of  a  full- 
time  child  without  any  great  difficulty.  The  practitioner  was  aware 
of  the  presence  of  a  cystic  tumour.     Shortly  after  delivery  she  com- 


284  OPERATIVE   Mll»\\  ll'Kl;V 

plained  of  abdominal  pain,  which  steadily  increased.  A  diagnosis  of 
an  ovarian  cyst  with  a  twisted  pedicle  was  made,  and  the  abdomen 
opened.  The  tumour  was  found  intimately  adherent  to  the  surround- 
ing structures.  It  was  removed  with  no  great  difficulty.  Two  com- 
plete t\\i>ts  from  left  to  right  were  found  in  the  pedicle.  The  patient 
died  the  day  following  the  operation. 

All  operators  refer  to  the  complications  which  1  have  mentioned. 
Doran  says  that  in  fifteen  cases  operated  upon  shortly  after  birth, 
there  were  no  complications  in  only  three,  and  Kynoch,1  in  three  cases 
operated  upon  during  the  puerperium,  found  necrosis  in  one  and  sup- 
puration in  another. 

Bearing  in  mind  such  records,  it  is  always  advisable  to  remove  the 
tumour  as  soon  as  possible  after  delivery,  and  immediately  any  un- 
toward symptom  appears.  I  have  removed  upon  three  occasions  an 
ovarian  cyst  early  in  the  puerperium.  In  the  one  case  the  operation 
was  performed  on  the  second  day,  and  in  two  on  the  fourth  day  after 
the  confinement.  The  results  in  all  cases  were  highly  satisfactory, 
and  none  of  the  patients  were  much  disturbed. 

1  Journ.  o/Obst.  and  Gyn.  Brit  Empire,  September.  1906,  p.  270. 


CHAPTEE  XVI 

DYSTOCIA  THE  RESULT  OF  ABNORMALITIES  AFFECTING  THE 
PARTURIENT  Q  AS  kL- Continued 

Fibro-Myoma  of  the  Uterus. 

n  considering  the  subject  of  fibro-myornata  and  parturition,  I  have 
ound  it  impossible  to  do  so  without  also  discussing  these  tumours  as 

<hey  affect,  or  are  affected  by,  pregnancy  and  the  puerperium.  I 
i;ive,  however,  omitted  entirely,  as  being  outside  the  province  of  this 

irork,  the  question  of  the  influence  which  the  tumours  have  upon 
ertility — a  subject  which  has  aroused  a  considerable  amount'  of 
nterest  in  recent  years. 

It  appears  to  me  desirable  to  consider  the  subject  under  the 
ollowing  heads :  (1)  The  effect  fibro-myomata  have  upon  pregnancy, 
abour,  and  the  puerperium ;  (2)  the  effect  pregnancy,  labour,  and 
he  puerperium  have  upon  fibro-myomata;  (3)  diagnosis;  (4)  treat- 

'•  nent. 

1.  The  Effect  Fibro-Myomata  have  upon  Pregnancy,  Labour, 
and  the  Puerperium. 

The  frequency  with  which  myomatous  tumours  of  the  uterus  are 
mcountered  in  the  pregnant  and  parturient  is  most  difficult  to 
estimate,  as  is  evidenced  by  the  figures  of  different  writers,  for  while 
)ne  observer  only  records  tumours  of  considerable  size,  another 
ncludes  every  small  nodule  which  he  happens  to  recognize  when 
palpating  the  gravid  uterus.  In  the  Clinique  Baudelocque,  during 
;he  ten  years  ending  December,  1904,  Pinard  found,  out  of  21,891 
leliveries,  171  women  with  fibro-myomatous  tumours  (0"7  per  cent.). 
Although  I  cannot  give  my  own  figures,  I  am  not  surprised  at  this 
ipparently  high  percentage,  for,  in  common  with  others,  I  have  found 
myomata  very  frequently  when  palpating  the  uterus  during  pregnancy 
and  labour. 

The  frequency  of  these  growths  is  of  interest  quite  apart  from  the 

235 


\ 


286  OPERATIVE   MlhWIl'l.n 

abstract  question  of  frequency,  for  it  is  evidence  of  the  enormoij ,.&\ 
number  of  women  who  are  performing  their  various  duties,  an<l  m<n' 
particularly  that  of  reproduction,  without  being  much  disturbed  1 
the  presence  of  these  tumours.     Indeed,  so  much  has  this  impress 
all   specialists  who   have   had    experience  of   obstetrics,  as  well 
gynaecology,  that,  speaking  generally,  their  attitude  towards  myoma 
complicating  pregnancy  and  parturition  is  very  conservative. 

In  the  Glasgow  Maternity  Hospital  during  the  last  ten  years,  i 
which  time  we  have  had  fully  35,000  cases  of  labour,  as  far  as  I  ce 
discover,  cceliotomy  has  only  been   necessary   upon  four  occasion 
At  various  times,  in  recent  years  when  the  subject  has  been  discuss* 
at   the    different   obstetrical   societies,   all  the   leading   obstetriciai 
have  pointed  out  the  infrequency  with  which  major  operation-  I 
necessary  in  pregnancy  and  labour.     This  was  very  strikingly  see 
at   the    Obstetrical    Section   of   the  Annual  Meeting   of   the  Britis 
Medical  Association  in  July  of  last  year,  when  the  subject  was  undi 
special  consideration.     In  America  it  is  exactly  the  same ;  while  i 
France  such  an  authority  as  Pinard  stated  that  for  the  years  L89J 
1901   inclusive,  in   14,000   cases,  myomata  were    found   present   ^ 
eighty-four.     Of  these,  sixty-six  went  to  term,  thirteen  bad  prematui 
labour,   and  five  aborted;    in   only  four  cases  was  it  necessary  t 
interfere  with  the  pregnancy.     In  Germany  the  views  of  practisin 
obstetricians  and  gynaecologists  are  equally  emphatic,  as  witness  tb 
recent  writings  of  Olshausen,  Hofmeir,  Winter,  and  a  host  of  otherj 
But  having  said  so  much  regarding  the  harmlessness  of  fibre 
myomatous  tumours  of  the  uterus  in  pregnancy  and  parturition,  le 
us  consider  the  complications  which  do  arise  occasionally  as  a  resuli 
of  their  presence. 

Naturally,  one  would  expect  that  the  presence  of  myomata  in 
gravid  uterus  would  predispose  to  abortion  and  haemorrhage,  and  this 
indeed,  is  so.  The  frequency  of  such  occurrences,  however,  has  beei 
overestimated,  for,  except  in  cases  where  the  tumours,  by  their  siz 
and  disposition,  interfere  with  the  growth  of  the  uterus  and  with  it 
circulation,  they  are  surprisingly  infrequent. 

Undoubtedly,  the  most  important  disturbances  produced  by  myo 
mata,  and  those  which  most  generally  furnish  the  indication  fo 
operative  interference,  are  the  symptoms  generally  referred  to  aj 
'pressure  symptoms.'  The  growing  tumour  and  uterus  increase  ii 
size  to  such  an  extent  that  the  functions  of  the  surrounding  organ 
are  interfered  with,  more  especially  if  the  tumour  is  impacted  in  tH 
pelvis  (Fig.  122).  The  organs  most  commonly  pressed  upon  are  ttii 
bladder,  urethra,  and  bowel ;  but  the  larger  vessels,  especially  thl 
veins,  may  have  their  circulation  interfered  with,  and,  if  the  tumou: 


FIBRO-MYOMA  OF  THE  UTERUS 


237 


iid  uterus  grow  to  an  enormous  size,  cardiac  and  respiratory  functions- 
I're  very  much  disturbed. 

While  slight  interference  with  the  structures  and  organs  named 

tay  be  permitted,  whenever  disturbances  in  them  become  marked 
fad  relief  cannot  be  obtained  by  rest  and  ordinary  means,  operative 
fiterference  becomes  imperative. 


Fig.  122. — Fibro-Myomata  associated  with  Pregnancy.     (Author's  Case.) 


An  unfavourable  situation  of  the  placenta,  more  especially 
dacenta  preevia,  has  been  frequently  referred  to.  Olshausen  says 
hat  implantation  of  the  placenta  over  the  tumour,  owing  to  its 
frequency,  is  more  than  a  coincidence.  He  thinks  that  possibly  the 
qucous  membrane  over  the  portion  of  the  tumour  being  thickened 
,nd  bulging  into  the  cavity  may  favour  the  implantation  of  the  ovum 


288  OPERATIVE  MIDWIFERY 

to  that  Locality.     Wertheim,1  however,  questions  tins,  and  refers  to| 
case  of  Schwarzenbach,  where  the  portion  of  the  placenta  Bitaaw 

over   the   tumour   was   very   thin    and    poorly   developed.      Mann 
removal  of  the  placenta  may  be  rendered  difficult  by  the  intima 
connexion   between    placenta   and  tumour,  and    by  the  difficulty 
reaching  the  placenta  owing  to  the  tumour.      Puppel     in   om 
after  repeated    attempts,  found  it  necessary  to   remove   the    patie] 
to  hospital  and  have  hysterectomy  performed. 

Retrodisplacement  of  the  uterus,  even  incarceration,  has  heel 
observed  once  or  twice,  and  a  few  years  ago  1  saw  a  sacculation  d 
the  gravid  uterus  caused  by  a  myoma  of  the  anterior  wall. 

It  is  very  doubtful,  however,  if  spontaneous  rupture  of  the  uterc 
during  pregnancy  has  ever  resulted.   Olshausen  very  rightly  questiol 
Hagan's  case.3     Eckstein4  records  a  case  where  rupture  followed 
very  difficult  extraction,  owing  to  a  submucous  myoma  obstructin 
the  canal;  but  in  that  case  the  rupture  was  not  spontaneous. 

Fibro-myomata  of  the  uterus  may  interfere  with  the  course  c 
labour  by  mechanically  hindering  the  progress  of  the  child  throng 
the  parturient  canal  and  by  distorting  the  uterus,  and  so  favourin 
malpresentations  and  malpositions  of  the  child. 

As  regards  dystocia,  of  much  greater  importance  than  the  size  c 
the  tumour  is  its  situation.  The  growths  which  cause  difficulty  ar 
those  situated  low  in  the  uterus,  especially  those  of  cervical  origin 
also  pedunculated  myomata,  as,  for  example,  a  case  which  wa 
recently  under  my  care,  and  is  described  later.  But  tumours  of  thi 
body  of  the  uterus,  if  they  extend  downwards  into  the  pelvis,  ma}T  als< 
give  trouble  during  parturition,  although  it  is  surprising  how  main 
of  these  growths,  even  when  of  considerable  size,  become  displace* 
from  the  pelvic  brim  by  the  uterine  retraction  or  by  slight  pressure! 
from  below.  The  explanation  of  such  cases  is  that  the  tumour  u 
really  implanted  in  the  uterine  body  above  the  lower  segment. 

If  the  tumour  only  overhangs  the  brim  during  pregnancy,  it  wil 
almost  certainly  not  cause  any  trouble  by  mechanically  narrowing  the 
canal  during  labour.  On  the  other  hand,  a  tumour  which  projects  intc 
the  pelvic  cavity,  and  is  not  pulled  out  of  it  by  the  uterine  contractions, 
nor  displaced  by  manual  pressure,  should  be  very  carefully  watched. 
and  operated  upon  if  the  pressure  upon  it  is  too  severe. 

Dystocia  may  also  result  from  unfavourable  positions  and  pre 
sentations  assumed  by  the  foetus.     This  applies  almost  exclusively 

1  Winckel's  'Handbuch,'  Bd.  ii.,  Teil  i..  p.  J 1 1. 

2  Deut.  Med.  Woch.,  December  17,  1908. 

3  Ann  r.  Journ.  of  Obat.,  vol.  xxvii.,  1898,  p.  305. 

4  Monat.f.  Geb.  u.  Oyn.t  J  id.  wiii..  Heft  ■  >. 


FIBKO-MYOMA  OF  THE  UTERUS  239 

to  tumours  situated  in  the  lower  portion  of  the  body  and  cervix.  h\ 
such  cases,  from  the  summaries  of  various  writers,  Olshausen  found 
vertex,  breech,  and  transverse  presentations  54  per  cent.,  24  per  cent., 
and  19  per  cent,  respectively. 

Lastly,  labour  may  be  disturbed  by  uterine  inertia  and  post-partum 
]];i  morrhage.  The  former  has  been  vaguely  referred  to  by  one  or  two 
writers ;  but  it  is  very  doubtful  if  it  is  much  more  common  in  women 
the  subjects  of  uterine  myomata  than  in  those  whose  uteri  are 
presumably  healthy.  Post-partum  haemorrhage  is  a  more  serious 
matter,  and  is  especially  favoured  by  implantation  of  the  placenta 
over  the  tumour.  A  case  of  the  kind  occurred  in  the  Maternity 
Hospital  a  year  or  two  ago. 


2.  The  Effect  of  Pregnancy,  Labour,  and  the  Puerperium  upon 
Fibro-Myomata  of  the  Uterus. 

But  while  labour  and  the  puerperium  may  be  disturbed  (as 
•described)  by  the  tumours,  the  latter,  in  their  turn,  are  liable  to 
various  alterations,  and  these  we  must  now  consider. 

The  most  evident  effect  pregnancy  has  upon  fibro-myomata  is  to 
■cause  an  increase  in  the  size  of  the  tumours.  For  the  most  part,  it 
is  only  interstitial  tumours  which  are  affected,  but  even  subserous 
growths  may  become  enlarged  if  their  attachment  to  the  uterus  is  still 
■extensive.  The  increase  in  size  is  very  largely  caused  by  cedema, 
although  there  also  occurs  a  distinct,  if  varying,  hypertrophy  of  the 
muscle  cells,  with  the  result  that  the  tumour  becomes  more  elastic. 
During  the  puerperium  the  size  decreases  with  the  involution  of 
the  uterus.  It  is  very  questionable  if  the  tumour  ever  disappears, 
although  a  small  nodule  is  sometimes  all  that  remains  of  a  large 
growth.  This  increase  of  the  tumour  during  pregnancy  and  its 
atrophy  during  the  puerperium  has  been  often  observed.  A  year  or 
two  ago,  however,  I  had  under  my  care  a  case  in  which  the  tumour 
did  not  decrease  after  pregnancy ;  indeed,  it  steadily  increased,  the 
pregnancy  appearing  to  start  its  active  growth. 

But,  besides  being  altered  in  size  and  consistency,  the  tumours 
often  become  altered  in  shape  by  the  gravid  uterus.  Very  often  they 
become  much  flattened  out,  and  if  situated  low  down  on  the  body 
wall  or  cervix,  this  may  result  in  a  portion  of  the  tumour  being  dis- 
placed downwards  into  the  pelvis.  Piecently  I  saw  a  patient  in  whom 
the  tumour  was  so  evenly  flattened  out  on  the  anterior  uterine  wall 
that  I  could  not  distinguish  it  from  the  anterior  wall  (Fig.  123). 
Indeed,  it  was  not  until  after  delivery  that  the  large  tumour  was 
recognized.     The  peculiar  feature  was  the  impossibility  of  palpating 


240 


OPERATIVE  MinwllT.HY 


the   fu'tal    purls,    and    the   impossibility,  on   the   most   careful    and 
repeated  examination,  of  discovering  any  evidence  of  the  foetal  heart. 

The  living  child,  which  was  lar^e,  was  delivered  with  forceps. 


Fi<:    128. — Large  Fibro-Myoma  in  Anterior  Wall  flattened  out.     (Author's  Case.) 

The  fcetal  parts  could  not  lie  felt,  nor  could  the  foetal  heart  sounds  be  heard.  The  child 
was  delivered  at  term  alive.  The  author  had  enucleated  a  large  fibroid  from  the  body 
of  the  uterus  sonic  six  years  before. 


FIBRO-MYOMA  OF  THE  UTERUS  241 

In  tumours  which  become  pedunculated,  torsion  of  the  pedicle 
has  very  occasionally  occurred.  The  features  of  such  a  complication 
are  the  same  as  those  which  follow  twisting  of  the  pedicle  of  an 
ovarian  cyst  :  severe  and  sudden  pain,  with  tenderness  over  the 
tumour,  and  sometimes  increase  in  its  size,  although  the  latter  feature 
is  not  so  marked  in  the  case  of  a  pedunculated  myoma.  At  any  time 
the  tumour  may  become  impacted  in  the  pelvis,  and  give  rise  to  all 
the  symptoms  characteristic  of  such  a  condition — great  pain,  nausea, 
dysuria,  and  difficult  defalcation.  Should  such  symptoms  be  present, 
and  the  tumour  intimately  connected  with  the  uterus,  it  may  be 
extremely  difficult  to  say  which  part  is  tumour  and  which  the  gravid 
uterus. 

Until  a  few  years  ago,  what  has  been  said  regarding  the  effect  of 
pregnancy  and  labour  upon  fibro-myomata  would  have  been  sufficient, 
as  the  only  recognized  reasons  for  interfering  with  such  growths 
were  pressure  symptoms  or  an  obstruction  in  the  parturient  canal. 
Recently,  however,  another  indication  for  operative  treatment  has 
been  brought  forward  by  some  writers,  and  in  this  country  more 
especially  by  Bland-Sutton — viz.,  degeneration  of  the  tumours.  This 
author  claims  that  degeneration  of  fibro-myomata  during  and  as  a 
result  of  pregnancy  is  a  common  occurrence,  and  so  far,  indeed,  has 
he  gone  that  he  recently  published  a  paper  entitled  '  The  Inimicality 
of  Pregnancy  and  Uterine  Fibroids.'1  While  obstetricians  and 
gynaecologists  are  greatly  indebted  to  Sutton  for  all  he  has  done  for 
gynaecology,  and  while  they  admire  the  cleverness  of  this  title,  they 
cannot  but  feel  he  has  greatly  exaggerated  the  danger,  in  all  proba- 
bility because,  being  a  general  surgeon,  he  sees  only  the  serious  cases 
of  fibro-myoma  in  pregnancy,  but  does  not  see  the  hundreds  of  cases 
which  they  see,  and  which  never  cause  any  trouble. 

A  special  feature  of  these  fibro-myomata  which  undergo  degenera- 
tion during  pregnancy  is  pain  and  tenderness  in  the  tumour.  The 
degeneration  is  very  generally  the  variety  known  as  '  red  degenera- 
tion,' in  which  the  cut  surface  of  the  tumour  resembles  a  raw  beef- 
steak. I  quite  agree  with  Sutton  that  pain  in  fibro-myomata  should 
always  arrest  attention ;  but  from  my  own  experience  I  do  not  attach 
the  same  importance  to  pain  in  these  tumours  in  pregnancy.  I  have 
seen  in  consultation  several  cases  of  myomata  complicating  preg- 
nancy in  which  pain  in  the  tumour  was  a  marked  feature.  In  all 
the  pregnancy  was  allowed  to  continue  undisturbed,  and  no  untoward 
symptoms  arose  either  during  parturition  or  the  puerperium.  I  in- 
formed the  medical  attendants  of  the  patients  that  I  was  prepared  to 
operate  at  any  time  if  any  unfavourable  symptoms  developed,  or  if 

1  '  Essays  on  Hysterectomy,'  1904. 

16 


242  OPERATIVE  Mll>\\  IIT.KY 

the  pain  became  excessive.     In  this  connexion  Stewart1  described   a 
case   in  which   a   myoma   associated   with    pregnancy  was   removed 

hecause  of  the  pain  complained  of.    The  tumour  presented  no  unusual 
appearance. 

As  hearing  upon  this  Bubject,  the  remarks  made  by  Pinard  on  two 
cases  shown  hy  Lepage-  are  of  special  interest  : 

'I  desire  to  add  some  further  information  about  the  two  patients 
whose  histories  M.  Lepage  has  just  related  to  you.  He  has  not  laid 
sufficient  stress  on  the  condition  of  the  women  when  they  entered  the 
Clinique  Baudelocque,  nor  of  the  treatment  which  was  there  followed. 
These  women,  with  the  uterus  crowded  with  fibroids,  suffered  terrible 
pain,  and  complained  continuously.  I  believe  that  many  surgeons, 
had  they  examined  at  that  moment,  would  have  thought,  in  view 
of  the  general  bad  condition  of  the  patients,  that  the  time  had 
come  for  surgical  interference,  and  would  have  performed  extirpation 
of  the  uterus.  I  ordered  these  women  complete  rest  in  bed,  a  milk 
diet,  and  regulated  the  urinary  and  intestinal  functions.  Little  by 
little  the  pain  passed  away  ;  there  has  been  no  haemorrhage,  and  in  the 
uterus  of  these  elderly  primipane,  crammed  with  fibroids,  the  children 
have  developed  sufficiently  to  be  born,  of  average  weight,  at  full  term.' 
I  have  also  found  the  pain  in  fibro-myomata  greatly  relieved  by 
regulating  diet  and  excretory  functions. 

But  apart  from  the  subject  of  the  degeneration  of  fibro-myomatous 
tumours  during  pregnancy,  which,  after  all,  is  a  matter  no  one  can 
generalize  upon  with  the  evidence  at  present  at  our  disposal,  there  is 
no  doubt  the  tumours  are  occasionally  injured  during  parturition. 
Here,  again,  situation  is  of  more  importance  than  size,  for,  naturally, 
tumours  in  the  upper  part  of  the  uterus  are  more  likely  to  escape 
injurious  pressure  than  those  situated  in  the  lower  areas  of  the  body 
and  cervix. 

Injuries  were  much  more  frequent  when  it  was  the  practice  to 
drag  the  child  past  the  tumour,  as  then  it  was  bruised  and  crushed 
between  the  foetal  head  and  maternal  pelvis.  As  in  ovarian  growths, 
the  injuries  to  the  tumours  may  not  be  immediately  evident,  the 
disturbances,  such  as  pain,  rise  in  temperature  or  pulse  from  infection, 
and  other  symptoms,  only  appearing  a  few  days  after  delivery. 
Personally,  I  have  been  struck  with  the  danger  of  infection.  I  have 
four  cases  in  my  mind,  three  of  them  seen  by  me  in  consultation 
after  delivery,  where  serious  septic  disturbances  followed  parturition. 
In  fact,  one  patient  died,  and  two  escaped  only  after  weeks  of  illness. 

1  Brit.  Med.  Jowrn.,  1906,  vol.  i.,  p.  548. 

2  Comptes  Rendu*  de  la  S<><-i>'t<:  d'Obstit.  de  (rijn.  et  de  Pid.  de  Paris,  October, 
1903  ;  ref.  Journ.  Obst.  Oyn.  Brit.  Empire,  1904,  vol.  v.,  p.  60. 


FIBEO-MYOMA  OF  THE   I'TEIUS  243 

In  all  the  tumours  were  situated  low  down  on  the  uterus,  and, 
although  no  great  force  was  used  in  delivering  the  child — for,  as  a 
matter  of  fact,  only  in  one  case  was  forceps  used — -I  have  little  doubt 
but  that  the  tumours  were  injured  during  parturition.  Hofmeir, 
writing  in  189(5,  says :  '  I  cannot  deny  that  I  have  often  contemplated 
the  puerperium  with  great  anxiety.'  In  a  later  paper1  he  speaks 
ess  seriously  of  the  condition.  Olshausen,  Winter,  Wertheim,  and 
many  other  Continental  writers,  express  similar  views.  The  practical 
bearing  of  this  is  that  the  puerperium  should  be  carefully  watched  in 
all  cases  where  the  tumour  has  been  compressed  between  the  foetus 
and  the  bony  canal,  and  the  tumour,  with  or  without  the  uterus, 
removed  should  any  complication  arise. 

Expulsion  of  the  tumour  from  the  uterus  during  or  after  delivery 
has  been  observed  by  several  writers.  A  few  years  ago,  when  ex- 
amining a  primipara  who  had  been  in  labour  some  hours,  I  discovered 
a  firm  body  within  the  os  and  slightly  in  front  of  the  presenting  head. 
At  first  I  took  it  to  be  the  cord,  but  on  more  careful  examination 
under  an  anaesthetic  I  discovered  it  to  be  a  flattened  myoma,  of 
about  the  size  of  a  pigeon's  egg.  I  removed  the  tumour,  and  allowed 
the  labour  to  proceed  (Fig.  73). 

A  most  interesting  case  is  one  reported  by  Seeligmann,'2  in  which 
that  operator  removed  by  '  morcellement '  a  submucous  myoma,  the 
size  of  a  foetal  head,  without  disturbing  an  eight  weeks'  pregnancy. 
The  tumour  was  forced  through  the  os  externum,  and  this  was 
accompanied  by  severe  pain  and  excessive  bleeding.  There  are  not  a 
few  records  of  such  tumours  being  expelled  during  the  puerperium. 
Many  years  ago  Priestley3  recorded  a  case  in  which  he  removed  one  on 
the  fourteenth  day  of  the  puerperium.  The  tumour  was  deeply  em- 
bedded in  the  uterus,  and  had  retarded  the  delivery  very  much. 
Herman4  showed  one  which  presented  at  the  os  uteri  ten  days  after 
delivery.     Many  similar  cases  have  been  described. 

Finally,  inversion  of  the  uterus  may  occasionally  follow,  and  a  few 
examples  of  that  accident  are  recorded  by  Tarnier  and  others.  Quite 
recently  Mackenrodt  reported  one.5 

1  Zeit.f.  Geb.  u.  Gyn.,  1900,  Bel.  xlii.,  p.  383. 

2  Zent.  f.  Gyn.,  1902,  No.  21,  p.  547. 

3  Lond.  Obsfc.  Soc.  Trans.,  vol.  i.,  p.  217.  *  Ibid.,  vol.  xxxiii.,  p.  31,  1892. 
5  Zeit.f.  Geb.  u.  Gyn.,  1903,  Bd.  xlix.,  Heft  1,  p.  145. 


•ill  OPERATIVE  MIDWIFKHY 

3.    Diagnosis  of  Fibro-Myomata  complicating  Pregnancy 

and  Labour. 

The  diagnosis  of  a  fibro-myonia  in  the  wall  of  the  gravid  uterus 
may  be  easy  or  difficult,  and  the  ease  or  difficulty  will  depend  very 
much  upon  the  form  and  situation  of  the  tumour  and  the  age  of  the 
pregnancy.  The  tumour,  which  is  irregular  in  outline,  projects 
laterally,  is  pedunculated,  and  pushes  the  uterus  over  to  the  opposite 
side  or  bulges  down  into  the  pelvis  and  displaces  the  uterus,  so  that 
it  is  almost  impossible  to  reach  the  cervix,  can  be  recognized  by  any- 
one. On  the  other  hand,  the  tumour  smooth  in  outline  and  moulded 
on  the  uterus,  as  in  a  case  I  have  already  referred  to,  may  be  im- 
possible to  differentiate  from  the  uterus. 

But  there  is  the  other  diagnostic  difficulty — the  recognition  of  the 
pregnancy.  If  the  pregnancy  is  still  only  of  a  month  or  two's  dura- 
tion, it  is,  as  a  rule,  impossible  to  be  quite  certain  of  its  existence  ; 
while,  on  the  other  hand,  if  it  has  advanced  to  mid-term  or  farther, 
one  can  usually,  unless  it  is  very  much  embedded  in  tumour  tissue, 
be  quite  certain  regarding  it. 

At  an  early  age,  when  the  abdominal  swelling  is  of  comparatively 
small  size — say,  about  the  size  of  a  sixteen  to  twenty  weeks"  pregnancy 
— mistakes  may  be  made  in  several  ways,  and,  to  illustrate  this,  let 
me  mention  a  very  striking  one  made  by  myself. 

Several  years  ago  my  house-surgeon  in  the  Glasgow  Maternity 
Hospital  and  I  diagnosed  a  subserous  myoma  complicating  pregnancy 
in  a  patient  who  was  sent  to  the  Maternity  Hospital  as  a  case  of  extra- 
uterine pregnancy.  She  complained  of  great  pain  and  tenderness 
over  the  uterus,  which  was  distended  by  an  eighteen  to  twenty  weeks' 
pregnancy.  On  palpating  the  abdomen,  an  elastic  swelling  could  be 
detected  in  the  antero-lateral  wall,  and,  presuming  that  the  pain  was 
caused  by  some  change  in  the  tumour  which  we  were  satisfied  we  felt, 
I  opened  the  abdomen.  Greatly  to  my  chagrin,  I  discovered  a  normal 
gravid  uterus,  without  the  slightest  trace  of  any  tumour  in  its  sub- 
stance or  its  neighbourhood. 

It  seems  extraordinary  that  such  a  mistake  should  occur.  That  it 
not  infrequently  happens,  however,  is  evidenced  by  the  fact  that  I 
have  twice  been  asked  to  see  similar  cases.  There  are  two  explana- 
tions of  such  phantom  uterine  tumours  during  pregnancy.  One  is 
that  portions  of  the  uterus  are  seized  between  the  palpating  hands, 
and  the  other  that  areas  of  the  gravid  uterus  contract,  and  sometimes 
remain  contracted  for  some  time.  The  latter  peculiarity  has  been 
remarked  on  by  several  writers,  but  by  none  in  so  interesting  a  manner 
as  by  Bar,  who  calls  attention  especially  to  a  partial  contraction  of 


FIBRO-MYOMA  OF  THE  UTERUS  245 

the  anterior  surface  of  the  uterus  associated  with  great  pain — exactly 
the  features  my  case  presented.  He  mentions  how  sometimes  it  is 
only  by  repeated  examinations  that  the  phantom  nature  of  the  tumour 
can  be  recognized. 

Upon  two  occasions,  with  very  unusual  varieties  of  extra-uterine 
pregnancy,  I  have  had  difficulty  in  making  up  my  mind  as  to 
whether  the  tumour  was  an  ectopic  sac  or  a  myoma  in  a  gravid 
uterus.  One  was  a  case  of  tubal  pregnancy  which  had  advanced  to 
about  the  thirty-sixth  week,  when  the  body  of  the  uterus  felt  like  a 
myoma,  and  the  sac  like  the  ordinary  gravid  uterus.  The  other  was 
an  interstitial  ectopic  pregnancy  of  about  the  fifth  month.  In  both 
cases,  however,  the  history  directed  one  to  a  correct  appreciation 
of  the  nature  of  the  swellings.  They  are  referred  to  and  figured  in 
Chapter  XXXII. 

Sometimes  for  a  week  or  two  one  is  in  doubt  as  to  whether  the 
tumour  one  feels  is  a  rapidly-growing  myoma  or  a  pregnancy.  In 
many  such  cases  it  is  both,  as  I  experienced  lately.  A  myoma  seldom 
grows  as  rapidly  as  a  gravid  uterus,  but  I  saw  one  recently  which 
started  growing  very  rapidly,  and  caused  the  patient's  physician  and 
myself  to  be  in  doubt  about  the  case  for  a  few  weeks.  Time,  however, 
invariably  clears  up  such  cases,  and  unless  there  is  some  great  urgency 
for  operating  it  is  as  well  to  delay  doing  so. 

If  the  tumour  is  subserous,  and  has  a  distinct  pedicle,  the  error 
may  very  easily  be  made,  as  happened  to  me  in  the  case  I  have 
recorded  (p.  251),  of  considering  the  neoplasm  ovarian  in  origin. 
Likewise,  if  the  tumour  is  submucous,  and  is  projecting  into  the  lower 
part  of  the  uterine  cavity,  it  may  be  mistaken  for  the  child's  head, 
or,  if  small,  for  the  cord,  which  happened  to  me  in  a  case  also  referred 
to  (p.  243).  Another  mistake  which  has  been  made  sometimes  with 
abdominal  tumours  of  this  size,  is  confusing  the  gravid  uterus  with  a 
pedunculated  fibroid.  As  all  are  aware,  in  the  gravid  uterus  about 
the  sixteenth  week  there  is  great  mobility  between  the  body  and 
cervix,  owing  to  the  softness  of  the  tissue  at  the  junction  of  these  two 
parts.  The  illustration  (Fig.  124)  explains  how  the  mistake  may 
arise — viz.,  through  the  examiner  pressing  the  cervix  between  his 
hands,  and  taking  it  for  the  entire  uterus. 

Then,  again,  if  the  myoma  is  spread  out  over  the  surface  of  the 
uterus,  the  tumour  or  the  pregnancy  may  be  overlooked.  If  the 
tumour  is  on  the  posterior  wall,  the  gravid  sac  is  readily  palpable  ; 
but  if  the  tumour  is  on  the  anterior  wall,  it  may  push  the  foetus 
altogether  out  of  reach,  as  in  the  case  illustrated  (p.  240).  In  such 
cases  a  rectal  examination  is  of  great  value.     Rosthorn.1  for  example, 

1  Ref.  Olshausen,  op.  cit. 


246 


OPEKATIVE  MIJ)W  II  \.\[\ 


was  able  to  get  ballottement  through  the  rectum  in  u  cum  where 
he  could  not  make  out  the  Ecetus  from  the  abdomen.  A  rectal 
examination  may  also  be  of  value  when  the  differential  diagnosis  is 
between  a  retroflexion  of  the  gravid  uterus  and  a  myoma  complicating 
pregnancy. 

The  important  symptoms  of  pregnancy — softening  of  the  cervix, 
partial  discoloration  of  the  vagina,  suppression  of  menstruation — are, 
with  few  exceptions,  present.  The  softening  of  the  cervix,  however, 
especially  when  the  tumour  is  situated  low  down  on  the  uterus,  is 
often  not  so  characteristic  as  in  an  ordinary  pregnancy,  although  it 
is  seldom  absent.     Discharges  of  blood  may  occur,  and  may  resemble 


Fig.  124. — Mistaking  a  Lateral  Flexion  of  tin   Uterus  Gravid  to  Four  Months 

for  a  Myoma. 


menstruation,  but  the}7  are  invariably  slight,  and  are  not  common 
unless  in  cases  of  abortion.  Still  later,  the  foetal  heart  sounds,  if 
present,  make  pregnancy  a  certainty,  but  their  absence,  even  in  the 
later  months,  does  not  exclude  it. 

In  the  other  class  of  cases,  where  it  has  been  decided  that  a  preg- 
nancy exists,  and  the  uncertainty  is  regarding  the  myoma,  onby  careful 
palpation  and  consideration  of  the  condition  can  decide  matters,  and 
my  advice  is,  in  all  cases  of  doubt,  to  take  time,  and  make  one  or  two 
examinations  before  coming  to  a  decision. 

It  has  occasionally  happened  that  mistakes  have  occurred  in  con- 
fusing a  myoma  with  a  second  fu-tus,  not  only  during  pregnancy,  but 
even  during  labour.  Indeed,  once  or  twice  an  accoucheur  has  waited 
patiently  for  what  he  thought  was  the  second  child,  when  what  he 
really  had  to  deal  with  was  a  large  myoma.  The  other  mistake  of 
confusing  a  second  child,  either  during  pregnancy  or  after  the  birth  of 
the  first,  with  a  myoma  is  less  excusable. 


FIBEO-MYOMA  OF  THE  UTEUI  S  247 


4.  Treatment  of  Fibro-Myomata  complicating-  Pregnancy, 
Labour,  and  the  Puerperium. 

What  has  been  said  regarding  the  features  of  fibro-myomata  in  the 
pregnant  and  the  parturient  may  have  left  the  reader  in  some  doubt 
as  to  the  indications  for  surgically  interfering  with  them.  Before  dis- 
cussing, therefore,  the  methods  of  operating,  let  me  in  a  word  or  two 
summarize  my  previous  remarks,  and  indicate  the  cases  in  which 
interference  is  necessary. 

1.  Tumours  should  only  be  removed  during  pregnancy  if,  on  the 
one  hand,  they  are  distinctly  endangering  the  life  or  seriously  disturb- 
ing the  functions  and  general  health  of  a  patient,  and,  on  the  other 
hand,  if  they  are  undergoing  serious  degeneration  or  injury.  Also,  in 
the  interests  of  the  child,  when  at  all  possible,  interference  should  be 
delayed  until  the  later  weeks  of  pregnancy. 

2.  Speaking  generally,  whenever  a  tumour,  at  the  end  of  pregnancy 
or  during  labour,  is  decidedly  obstructing  the  parturient  canal,  and 
that  tumour  cannot  be  displaced  out  of  the  pelvis,  it  should  be  removed, 
with  or  without  the  uterus. 

3.  All  tumours  which  have  been  injured  during  labour,  or  which 
show  signs  of  undergoing  marked  degeneration,  or  have  become  infected 
after  parturition,  should  be  removed,  with  or  without  the  uterus,  as 
early  as  possible. 

One's  attitude,  therefore,  to  fibro-myoma  in  the  pregnant  is  to 
operate  only  if  interference  is  distinctly  indicated.  All  gynaecologists 
who  have  had  experience  of  obstetrics  operate  upon  myomata  in 
pregnancy  as  seldom  and  as  late  as  possible. 

Pregnancy. — When  a  fibro-myoma  causes  such  disturbances  in 
pregnancy  that  interference  becomes  necessary,  it  will  be  found  very 
often  that  the  tumour  is  impacted  in  the  pelvis.  In  certain  cases,  by 
digital  pressure  from  the  vagina,  with  the  patient  in  the  knee-elbow 
or  Sims'  position,  the  growth  may  be  dislodged  ;  but  in  a  very  large 
proportion  that  simple  treatment  fails,  and  more  radical  methods  have 
to  be  employed. 

In  former  years  induction  of  abortion,  or,  if  the  pregnancy  had 
advanced  to  the  later  weeks,  induction  of  premature  labour,  was  the 
treatment  generally  recommended  and  practised.  Such  treatment, 
however,  has  been  entirely  abandoned.  For  my  part,  I  can  conceive 
of  few  circumstances  under  which  it  is  indicated,  for,  even  if  it  is 
successfully  carried  out — and  that  is  not  always  an  easy  matter, 
owing  to  the  distortion  of  the  uterus — one  has  in  no  way  improved 
the  condition  of  the  woman,  for  the  operation  would  require  to  be 


is  Ol'KKATIVK   MIDWIFERY 

repented  should  she  again  become  pregnant.  J  have  Baid  there  are 
few  circumstances  under  which  premature  emptying  of  the  uterus 
is  indicated,  and  some  may  say  there  are  none.  I  could,  however, 
conceive  it  justifiable  if  the  woman  was  suffering  from  some  grave 
concurrent  disease  which  rendered  an  abdominal  operation  a  matter 
of  extreme  gravity.  Even  in  such  a  case,  however,  the  accoucheur 
would  require  to  satisfy  himself  that  the  bringing  on  of  abortion  or 
labour  would  not  be  a  greater  tax  upon  the  woman  than  abdominal 
section. 

In  only  a  comparatively  few  cases  is  it  possible  to  remove  the 
tumour  by  the  vagina.  Small  pedunculated  myomata  lodged  in 
Douglas'  pouch,  pedunculated  submucous  tumours  projecting  from 
the  os,  and  cervical  myomata  of  small  size,  may.  however,  be 
removed  by  that  route,  and  in  many  cases  without  disturbing  the 
pregnancy. 

Enucleation  of  a  cervical  myoma  from  the  vagina  should  only  be 
attempted  if  the  tumour  is  of  moderate  size  and  entirely  in  the  pelvis. 
It  is  sometimes  not  easy  to  decide  such  a  matter,  for  only  a  portion  of 
the  tumour  may  be  projecting  into  the  pelvis.  One  can  usually  tell, 
however,  if  there  is  any  mass  above,  by  pushing  the  uterus  or  child 
into  the  pelvis  and  observing  how  the  tumour  descends.  Also,  by 
making  a  rectal  examination  one  may  be  able  to  define  the  tumour 
if  it  is  situated  behind  the  uterus.  It  is  not  wise  to  attempt  to 
remove  large  myomata  by  enucleation  through  the  vagina  :  nor  are 
the  extensive  vaginal  incisions  recommended  byDiihrssen  suitable  for 
such  cases. 

By  far  the  largest  proportion  of  cases  which  require  surgical  inter- 
ference cannot  be  safely  attacked  from  the  vagina,  but  must  be 
approached  from  the  abdomen. 

When  abdominal  interference  is  deemed  necessary  in  cases  of 
myomata  complicating  pregnancy,  the  operator  has  two  alternatives 
to  choose  from — removal  of  the  tumours,  and  hysterectomy  in  some 
form  or  other.  It  will  be  admitted  by  all  that,  if  a  myoma  is 
pedunculated,  the  rational  treatment  is  to  ligate  and  divide  the 
pedicle,  just  as  one  would  do  in  the  case  of  an  ovarian  cyst. 

But  of  much  greater  interest  are  the  results  following  myomectomy 
or  enucleation.  The  operation  of  enucleation  has  come  into  great 
favour  in  recent  years,  and  very  rightly  so,  for,  theoretically,  it  is  the 
ideal  operation.  There  is  this  also  to  be  said  in  its  favour  when 
employed  on  the  gravid  uterus,  that  at  such  a  time  one  sees  the 
uterine  tumours  at  their  worst,  for  they  are  much  enlarged,  and  if 
they  happen  to  be  multiple  they  are  much  more  distinct.  In  two 
respects   the   operation    is   a   most   satisfactory   one.      The   existing 


FIBRO-MYOMA  OF  THE  UTEEUS  249 

pregnancy  is  disturbed  in  less  than  a  third  of  the  cases,  and  the 
uterus  is  left  for  future  pregnancies. 

In  this  country  in  recent  years  there  have  been  many  cases 
recorded,  and  a  great  many  more  which  have  never  been  reported. 
Djnald1  and  Sutton2  have  each  referred  to  cases  in  which  they  had 
enucleated  a  fibro-myoma  from  the  gravid  uterus  without  disturbing 
the  pregnancy;  while  Thring3  has  reported  six  cases,  all  of  which 
recovered,  and  in  five  of  which  pregnancy  was  undisturbed.  Equally 
good  results  have  been  described  by  Doran4  and  Routh.5 

It  is  evident,  therefore,  that  the  treatment  of  fibromyomata  by 
enucleation  is  most  encouraging,  and,  if  the  tumours  were  only  single, 
would  be  the  method  invariably  employed.  In  many  cases,  however, 
this  variety  of  tumour  is  multiple,  and  the  uterus  is  so  extensively 
invaded  that  there  is  no  possibility  of  removing  all  the  tumours.  As 
regards  such  cases,  when  many  tumours  exist,  it  is  quite  impossible  to 
lay  down  any  hard-and-fast  rules  regarding  treatment.  Emmett6 
removed  nine  myomata  from  a  gravid  uterus  without  disturbing  the 
pregnancy. 

Another  matter  of  satisfaction  is  that,  even  although  the  tumour 
is  deep  in  the  uterine  wall,  it  may  be  enucleated  with  safety  to  the 
patient  and  the  foetus.  Several  cases  have  been  recorded  where  the 
operator  actually  exposed  the  decidua.  Of  such  cases,  one  described 
by  Mackenrodt  is  most  interesting.  A  woman  three  months  pregnant 
complained  of  pain  and  fever.  Mackenrodt  considered  it  to  be  arising 
from  a  uterine  myoma  undergoing  degeneration.  He  enucleated  the 
tumour,  and  in  doing  so  exposed  the  decidua.  The  patient  recovered 
and  did  not  abort. 

The  ease  with  which  the  tumour  comes  out  of  its  bed  during 
pregnancy,  and  especially  during  the  puerperium,  is  well  known  to 
all  operators,  so  that  part  of  the  operation  is  comparatively  simple. 
The  treatment  of  the  raw  surface  left  is  of  greater  importance. 
Donald7  recommends  closing  it  in  layers,  and  uses  catgut.  He 
attaches  great  importance  to  making  very  shallow  layers,  as  other- 
wise too  much  tension  is  thrown  on  the  uterine  wall,  and  in  that 
way  he  thinks  abortion  is  favoured.  Certainly,  careful  stitching  of 
the  uterine  wound  is  of  the  greatest  importance,  for,  apart  altogether 
from  the  risk  of  abortion,  which,  after  all,  although  disappointing,  is 
not  serious,  there  is  the  distinct  danger  of  rupture  of  the  uterus  and 

1  Lond.  Obst.  Trans.,  vol.  xliii.,  p.  180.  2  '  Essays  on  Hysterectomy,'  1904. 

3  Journ.  Obst.  and  Gyn.  Brit.  Empire,  September,  1906. 

4  Brit.  Med.  Journ.,  1906,  vol.  ii.,  p.  1446. 

5  Clinical  Journal,  May  23,  1906.         6  Amer.  Journ.  of  Obst.,  September,  1901. 
7  Lond.  Obst.  Trans.,  vol.  xliii. 


250  OPERATIVE  MIDWIFER1 

hemorrhage.  I  can  find  no  recorded  case  of  rupture  following.  J>ut 
there  have  been  several  where  haemorrhage  from  the  uterine  wound 
continued  and  necessitated  the  removal  of  the  uterus. 

But  more  frequently  the  operator  chooses  hysterectomy.  N" 
doubt  the  brilliant  results  obtained  by  operators  in  this  and  other 
countries  will  encourage  others  to  consider  fully  the  advantages  of 
enucleation  before  having  recourse  to  an  operation  which  removes  all 
chance  of  subsequent  pregnancies. 

The  two  methods  of  hysterectomy,  open  to  one  before  the  child  is 
viable,  are  supravaginal  amputation  and  the  removal  of  the  entire 
uterus,  or  panhysterectomy.  Naturally,  if  the  child  is  viable,  one 
would  first  perform  Cesarean  section.  As  all  operators  are  agreed 
that  panhysterectomy  is  a  little  more  difficult  and  complicated  than 
supravaginal  hysterectomy,  and  as  its  mortality  is  slightly  higher 
(although  the  statistics  do  not  support  the  last  contention),  it  is 
apparent  that  supravaginal  amputation  is  the  operation  of  choice, 
and  panhysterectomy  need  only  be  had  recourse  to  under  special 
circumstances.  The  most  obvious  compelling  circumstance  is  when 
the  tumour  or  tumours  have  so  altered  the  position  and  shape  of 
the  cervix  as  to  render  amputation  through  it  wellnigh  impossible. 
Another  indication  is  infection  of  the  cervical  canal. 

The  mortality  in  non-infected  cases  is  not  higher  than  5  per 
cent. 

Labour. — Before  considering  in  detail  the  different  methods  of  treat- 
ment of  fibro-myomata  in  labour,  let  me  caution  against  dragging  the 
child  by  force  past  a  tumour.  Such  treatment  is  most  unwise.  Conse- 
quently, forceps,  version,  and  craniotomy,  be  the  child  dead  or  alive, 
do  not  come  into  consideration  at  all,  unless  the  obstruction  is  so 
slight  as  to  be  almost  negligible.  It  is  quite  unnecessary  for  me  to 
give  figures  to  prove  the  disastrous  results  following  such  treatment 
as  forcible  extraction  with  forceps,  version,  craniotomy,  induction  of 
labour,  and  abortion ;  and,  indeed,  I  could  only  give  old  statistics, 
such  as  those  of  Siisserott  and  Lefour,  published  many  years  ago. 
Only  if  one  were  placed  in  some  out-of-the-way  country  district 
would  the  treatment  be  justifiable.  Under  such  circumstances, 
however,  I  would  consider  the  risks  of  a  long  journey,  even  a  very 
long  journey,  to  a  hospital  or  nursing  home  infinitely  less  grave  than 
those  involved  in  pulling  a  child  by  force  past  an  obstructing  fibro- 
myoma. 

Many  of  the  tumours  which  project  into  the  pelvis  may  be  pushed 
up,  and  are  even  dragged  up,  by  the  contractions  of  the  uterus. 
Tumours  of  the  cervix,  however,  cannot,  as  a  rule,  be  so  dealt  with. 
They  must  either  be  removed  by  the  abdomen  or  by  the  vagina. 


FIBRO-MYOMA  OF  THE  UTERUS  251 

AVI i en  possible  they  should  be  removed  by  enucleation.  They 
can,  as  a  rule,  be  easily  shelled  out  after  the  capsule  is  split. 
Amongst  the  early  recorded  cases  of  vaginal  enucleation  of  cervical 
fibroids  is  the  one  described  by  Braxton  Hicks.1  He  tried  to 
deliver  with  forceps,  but  failed.  The  tumour  was  easily  enucleated, 
and  he  delivered  a  living  child  with  forceps.  A  recent  case  of  this 
nature  is  one  described  by  Piobinson,'2  where  a  large  myoma  growing 
from  the  posterior  lip  of  the  cervix  was  enucleated,  and  afterwards  the 
child  was  delivered  with  forceps. 

The  simplest  of  all  myomata  to  remove  are  the  pedunculated. 
They  may  be  either  subserous  or  submucous.  An  example  of  a 
submucous  one  which  occurred  in  my  practice,  and  was  removed 
during  labour,  has  been  already  referred  to  (p.  243).  Here  is  a  short 
report  of  a  pedunculated  and  subserous  myoma  which  obstructed 
labour,  and  was  under  my  care  a  few  years  ago  : 

Mrs.  A ,  a  multipara,  was  admitted  to  the  Glasgow  Maternity  Hospital 

advanced  in  labour.  The  os  was  fully  dilated,  but  the  child,  which  presented 
by  the  vertex,  could  not  be  expelled  because  of  a  tumour  which  occupied  the 
pouch  of  Douglas.  The  tumour  was  very  tense,  and  was  about  the  size  of  a 
closed  fist.  It  could  not  be  displaced  from  the  pelvis,  as  it  and  the  foetal 
head  were  firmly  impacted  in  the  cavity.  I  took  the  tumour  for  an  ovarian 
cyst.  As  the  case  seemed  peculiarly  suited  for  vaginal  cceliotomy,  I  made 
an  incision  over  the  tumour  through  the  posterior  fornix  of  the  vagina. 
Without  the  least  difficulty,  and  with  little  or  no  bleeding,  the  pouch  of 
Douglas  was  opened  into,  and  the  tumour,  which  was  evidently  solid,  seized 
with  volsellum  forceps.  On  pulling  it  through  the  vagina  it  was  found  to  be 
a  pedunculated  myoma.  Having  transfixed  the  pedicle,  I  Avas  proceeding  to 
tie  the  ligatures  when  the  pedicle  tore  across,  as  far  as  could  be  judged,  at  the 
point  where  it  was  attached  to  the  uterus.  Finding  no  vessel  of  any  size  in 
examining  the  pedicle,  which  came  away  with  the  tumour,  I  did  not  feel 
concerned  about  its  having  given  way.  As  a  precaution,  however,  I  put  a 
strip  of  gauze  into  the  pouch  of  Douglas.  I  then  proceeded  to  extract  the 
child  with  forceps.  That  was  very  easily  accomplished,  and  the  child  was 
alive.  The  placenta  was  expelled  without  difficulty.  Finally,  I  removed  the 
gauze  from  Douglas'  pouch,  and,  finding  it  was  not  blood-stained,  I  closed 
the  vaginal  wound.     The  patient  made  an  uninterrupted  recover)'. 

One  would,  of  course,  only  think  of  vaginal  cceliotomy  if  the  tumour 
projected  into  the  pelvis  and  was  of  small  size.  Myomata  with  such 
a  long  pedicle  are  very  uncommon,  so  that,  although  the  operation 
described  is  one  suited  for  ovarian  tumours,  it  is  seldom  that  myomata 
can  be  so  treated. 

1  Trans.  Lond.  Obst.  Soc,  vol.  xii.,  p.  273. 

2  Brit.  Med.  Journ.,  1906,  vol.  ii.,  p.  1637. 


252  OPERATIVE  MIDWIFERY 

Although  in  many  cases  it  is  an  advantage,  when  possible,  to 
operate  before  Labour  lias  started,  it  is  not  always  a  wise  proceeding, 
for  there  is  a  fair  number  of  cases  on  record  where,  us  the  labour  has 
progressed,  the  tumour  has  been  drugged  up.  If,  therefore,  there  is 
any  prospect  of  such  a  termination — and  1  have  already  indicated  the 
cases  in  which  such  an  occurrence  might  he  expected — it  is  advisable 
to  delay  operation  until  later. 

In  those  cases  in  which  a  more  extensive  operation,  than  simple 
removal  of  a  pedunculated  tumour  is  necessary,  the  following  courses 
are  open,  and  I  mention  them  in  the  order  in  which  they  would  com- 
mend themselves  to  one  anxious  to  conserve  the  uterus  as  far  as 
possihle,  and  at  the  same  time  do  the  best  for  the  mother  : 

1.  Myomectomy  followed  by  extraction  of  the  child  per  vias 
natural*  *. 

2.  Cesarean  section  followed  by  myomectomy. 

3.  Hysterectomy. 

4.  Conservative  Cesarean  section. 

Not  a  great  deal  need  be  said  regarding  these  methods.  The 
conditions  which  guide  one  to  choose  enucleation  during  labour  are 
the  same  as  those  which  should  influence  one  in  choosing  that  method 
during  pregnancy. 

Vaginal  myomectomy  during  labour  has  already  been  referred  to 
(p.  250).  Abdominal  myomectomy  followed  by  extraction  of  the 
child  per  vaginam  with  forceps,  version,  etc.,  can  only  be  resorted  to 
when  labour  is  far  advanced  and  the  os  fully  dilated,  for  no  one  would 
care  to  allow  a  uterus  from  which  a  myoma  had  been  recently 
enucleated  to  have  many  hours  expelling  a  child.  True,  one  might 
incise  the  cervix,  but  it  is  a  question  if,  by  adopting  such  a  course, 
one  is  not  pushing  a  method  beyond  its  rational  limits.  The  same 
applies  to  delaying  operation  until  the  os  is  sufficiently  dilated, 
for  the  tumour  hinders  dilatation.  In  this  connexion,  I  find  a  case 
reported  by  Olshausen  where  a  myoma  was  removed  by  the  abdomen, 
and  afterwards  the  dead  child  delivered  by  forceps.  Calderini1  records 
a  case  of  enucleation  and  closure  of  the  abdomen  and  delivery  by 
version. 

The  second  method  mentioned,  Casarean  section  followed  by 
myomectomy,  is  the  course  to  be  followed  in  those  cases  where  the 
tumour  cannot  be  enucleated  until  the  uterus  is  emptied.  "We  have 
already  seen  that  one  is  compelled  sometimes  to  adopt  a  similar 
course  with  ovarian  cystomata  obstructing  labour.  If  such  a  course 
is  necessary,  it  is  advisable  to  turn  the  uterus  out  and  make  the 
(  a  sarean  section  wound  in  such  a  position  that  an  extension  of  it  wil 

1  Zcnt.f.  (1  ;/?>.,  1890. 


FIBRO-MYOMA  OF  THE  UTERUS 


25$ 


permit  of  the  removal  of  the  tumour.     Olshausen1  mentions  some 
good  results  from  this  method. 

It  is  the  form  of  treatment  which  should  be  employed  when  the- 


Fig.  125. — Uterus  with  Fibro-Myomata,  and  containing  a  Full-time  Child,  removed  by 
Panhysterectomy  during  Labour.     (Bland-Suttun.1 

tumour  is  single,  but  it  is  very  questionable  if  it  is  advisable  when 
there  are  several  tumours. 

Without  doubt  the  third  method  of  treatment — hysterectomy — is 
the   method   generally  favoured,  and   rightly  so,  for   the    uterus   is 
1  Yeit's  '  Handbuck  Gyn.,'  2nd  edition,  1907. 


254  OPERATIVE  MIDWIFERY 

generally  boo  extensively  <  1 1 - . . l - .  < I  to  l>e  ol  much  Future  service,     in 
most  oases     they  are  not  many    the  child  has  first  been  removed  by 
larean   Bection,   bat   in   an   interesting  ca  ibed   by   Sutton 

(Fig.  L25j  the  whole  a  terns  was  removed  with  the  child  in  situ.    The 
latter  proceeding  is  only  justifiable  if  the  child  ie  dead.     With  a 

iving  child,   and,    indeed,   if    there    is   the   slightest    possibility   of  its 

ueing  alive,  the  uterus  in u - 1  be  opened  into  and  the  child  extracted 

■•re  one  proceeds  to  hysterectomy;  for  although  there  is  one  case 
on  record  where  the  uterus  was  opened  into  after  its  removal  and  yet 
the  child  was  alive,  that  does  not  justify  one  in  following  ~uch  a 
procedure. 

Sere,  again,  the  choice  is  between  supravaginal  amputation  and 
panhysterectomy.  As  in  the  case  of  hysterectomy  during  pregnancy, 
the  position  of  the  tumour  is  the  chief  influencing  circumstance.  But 
there  comes  in  also  the  danger  of  septic  infection  from  the  cervix,  so 
that  if  there  is  any  reason  to  he  suspicious  of  the  parturient  canal 
being  infected,  panhysterectomy  should  he  chosen.  Curiously,  the 
results  are  rather  better  with  panhysterectomy.  Although  I  have 
always  found  panhysterectomy  either  during  pregnancy  or  labour 
peculiarly  easy,  owing  to  the  looseness  of  the  cellular  tissue,  I  cannot 
quite  understand  why  the  latter  should  give  better  results  than  supra- 
vaginal amputation,  and  I  am  inclined  to  think  that  the  mortality  of 
the  two  must  be  very  much  the  same.  The  method  of  removing  the 
uterus  is  described  in  connexion  with  the  operation  of  Cesarean 
section  (Chapter  XXVI.). 

There  is  a  large  number  of  cases  on  record  where  conservative 
Cesarean  section  was  performed.  Personally,  I  think  the  simple  con- 
servative operation  incomplete,  for  the  tumour  or  tumours  are  left 
behind,  and  although  they  usually  diminish  in  size  very  decidedly 
after  delivery,  they  seldom  completely  disappear,  and  they  usually 
enlarge  again  in  subsequent  pregnancies.  The  conservative  operation 
was  the  one  employed  until  fifteen  or  twenty  years  ago,  and  Sanger  in 
L882  wrote  in  its  favour.1  The  results,  however,  have  not  been  good, 
although  it  must  he  remembered  that  one  is  comparing  figures  of 
operations  performed  fifteen  years  ago  with  those  performed  to-day. 
The  only  advocate  at  the  present  time,  as  far  as  I  know,  of  the  simple 
conservative  Cesarean  section  isLewers,2who  recorded  two  successful 
cases  a  few  years  ago. 

Puerperium.— Before  leaving  this  subject,  let  me  say  a  word  regard- 
ing myomata  which  give  trouble  during  the  puerperium.  These  are  for 
the  most  part  submucous  and  interstitial,  although  even  the  subserous 

1  •  1'ir  Kaiserschnitt  bei  Uterus-fibromen.' 

2  Loncl.  Obst.  Trans..  190.'.,  vol.  xlvi..  p.  117. 


FIBRO-MYOMA  OF  THE   I'TERUS  255 

may  occasionally  be  injuriously  affected  by  the  labour,  as  when  the 
pedicle  gets  twisted  or  the  tumour  gets  bruised.  Some  operators  go 
the  length  of  advising  the  removal  of  all  fibroids  immediately  after 
delivery.  But  this  is  unnecessary,  for  many  tumours,  as  every  one 
admits,  give  rise  to  no  trouble,  and  shrivel  up  and  become  very  small 
indeed.  The  only  variety  which  should  always  be  removed,  whether 
they  are  giving  trouble  or  not,  is  the  pedunculated  submucous. 

But  although  it  is  quite  unnecessary  to  operate  upon  all  cases, 
from  what  I  have  seen,  it  is  advisable  to  remove  the  tumour,  either 
with  or  without  the  uterus,  whenever  there  is  evidence  of  any  septic 
disturbance  in  the  puerperium. 

When  the  tumour  is  submucous,  the  simplest  proceeding  is  to  shell 
out  the  tumour,  and  that  is  easily  done  as  a  rule.  One  trouble,  how- 
ever, is  that  occasionally  there  is  very  profuse  bleeding  ;  Martin,  for 
example,  lost  two  patients,  although  the  tumours  were  removed  a 
fortnight  after  parturition.  Another  danger  is  infection,  particularly 
if  one  waits  until  there  are  distinct  indications  for  operating.  Speak- 
ing generally,  hysterectomy  is  safer  than  simple  myomectomy  in  cases 
where  the  tumour  is  infected,  and  panhysterectomy  is  the  best  method 
to  employ,  for  in  most  cases  the  whole  uterine  and  vaginal  canal  is 
infected. 


<  hatti: l;  \vn 

DYSTOCIA  THE  RESULT  OF  ABNORMALITIES  AFFECTING  THE 
PARTURIENT  CANAL— <  'ontinued 

Tumours  of  the  Bladder  and  Rectum. 

Tumours  of  the  Bladder. — When  speaking  of  tumours  complicating 
parturition,  I  mentioned  incidentally  the  case  referred  to  by  Smellie, 
where  a  vesical  calculus  obstructed  labour,  and  was  ultimately  forced 
out  of  the  bladder  per  vaginam.  McLintock1  refers  to  one  in  which 
a  large  stone  was  removed  from  a  woman  seven  months  pregnant 
without  disturbing  the  pregnancy.  Thomas  -  also  recorded  a  case 
operated  on  during  pregnancy.  Hugenberger,  in  his  monograph  on 
the  subject,  written  in  1875,  collected  twenty-three  cases.  In  many 
of  these  great  injury  occurred,  while  sometimes  the  tumour  was 
removed  during  labour  or  pushed  out  of  the  way.  Personally,  I  have 
nothing  to  say  regarding  the  condition,  for  I  know  of  no  case  of  the 
kind  having  occurred  in  the  Glasgow  Maternity  Hospital.  In  recent 
years  very  few  cases  have  been  recorded.  Rosenfeld3  has  described 
a  case  where  lateral  lithotomy  was  performed  at  the  fifth  month 
because  of  a  urinary  calculus  and  a  septic  condition  of  the  urinary 
tract.  Abortion  occurred  on  the  third  day,  and  the  patient  died  on 
the  fourth. 

Tumours  connected  with  the  bladder  are  very  rare  at  all  times. 
In  the  few  cases  where  they  have  arisen  from  the  neck  of  the  bladder 
they  might  well  cause  dystocia,  but  so  far  I  have  not  encountered 
such  a  case,  nor  have  I  seen  any  reference  to  it  in  obstetric  literature, 
although  I  doubt  not  the  condition  has  been  observed.  Vander- 
linden  '  describes  a  myxo-fibronia  removed  two  months  after  labour  at 
full  time.  During  the  patient's  pregnancy  there  had  been  no  bladder 
trouble  beyond  three  slight  attacks  of  hematuria.  Labour  was 
undisturbed,  but  on  the  sixth  day  of  the  puerperium,  on  pal- 
pating the  uterus,  a  tumour  of  some  size  was  discovered  above  the 

1  Smellie's  '  Midwifery,1  vol.  xi..  p.  101.  2  Lancet,  1888-89,  vol.  i.,  p.  58. 

■■  Munch.  Med.  Woch.,  No.  89,  1895.  '  B&LZeitf.  Gyn.,  1900,  p.  887. 


TUMOURS  OF  THE  BLADDER  AND  RECTUM  257 

symphysis  pubis.  Some  weeks  later  the  tumour  and  a  portion  of  the 
bladder  were  removed. 

Tumours  of  the  Rectum. — The  majority  of  tumours  of  the  rectum 
encountered  in  practice  are  of  a  malignant  nature.  This  is  espe- 
cially seen  in  the  cases  where  the  rectal  tumour  has  been  found 
complicating  pregnancy  or  labour.  Odd  cases  will  be  found  recorded 
where  the  tumours  have  been  of  a  simple  nature.  Quite  recently 
Alexandrow1  reported  one  where  a  pedunculated  fibroma  of  the 
rectum  obstructed  the  delivery  of  the  child.  During  extraction  with 
forceps  the  tumour  was  pushed  out  of  the  anus.  A  somewhat  similar 
case  was  described  many  years  ago  by  Barnes.2 

Carcinoma  of  the  rectum,  however,  is  the  chief  tumour  of  interest. 
As,  however,  I  have  had  no  personal  experience  of  the  condition,  I  am 
indebted  to  such  monographs  as  those  of  Hollander,3  Krause,4  A.  "W. 
Russell,5  and  Nighoff.6 

The  diagnosis  of  carcinoma  of  the  rectum  in  pregnancy  and 
labour,  if  the  tumour  is  of  any  size,  has  usually  presented  no  great 
difficulty,  although,  without  doubt,  there  have  been  many  cases  in 
which  the  condition  must  have  been  overlooked.  In  most  of  the 
cases  recorded  a  hard  mass  was  felt  pushing  the  posterior  vaginal 
wall  forward.  Sometimes,  however,  this  narrowing  of  the  canal  has 
been  very  slight,  for  the  delivery  was  spontaneous,  as  in  Kjelberg's7 
second  case,  where  an  inoperable  carcinoma  was  discovered  six  weeks 
after  a  normal  and  spontaneous  delivery,  and  Rossa's8  case,  where 
the  delivery  was  also  spontaneous  at  term. 

The  symptoms  of  the  condition  are  constipation,  with  occasional 
attacks  of  diarrhoea ;  in  a  few  cases,  as  Duncan's,9  even  intestinal 
obstruction.  Generally,  also,  there  has  been  pain  in  the  sacrum, 
tenesmus,  and  irregular  bleedings  from  the  rectum. 

The  effect  of  the  tumour  upon  parturition  has  been  variable.  As 
already  stated,  some  cases  have  terminated  spontaneously,  but  in 
most  there  has  been  distinct  obstruction — an  obstruction  which  has 
sometimes  been  so  great  as  to  necessitate  Cesarean  section.  In  man}7 
of  the  cases,  however,  the  child  has  been  dragged  past  the  tumour, 
sometimes  without  the  growth  being  much  injured;  but  on  other 
occasions  with  considerable  laceration  to  tissues. 

Speaking  generally,  the  circumstances  which  should  guide  one  in 

i  Bull.  Gen.  de  Therajp.,  April  30,  1905;  ref.  Zentral.  f.  Gyn.,  1906,  p.  1429. 

2  Lond.  Obst.  Trans.,  vol.  xxi.,  p.  28. 

3  ArcUvf.  Gyn.,  Bd.  xliv.  *  Inaug.  Dis.,  Bonn,  1900. 

5  Scottish  Med.  and  Surg.  Joum.,  June,  1903. 

6  Zent.  f.  Gyn.,  1905,  p.  881.  7  Op.  cit. 

8  Zent.f.  Gyn.,  1902,  p.  1241.  9  Lancet,  1898,  vol.  L,  p.  405. 

17 


OPERATIVE  MlDWll'KliV 

tli.'  treatment  of  carcinoma  of  the  rectum  complicating  pregnancy  and 
labour  are  very  much  the  Bame  ae  those  which,  as  we  have  already 
Been,  guide  one  in  dealing  with  carcinoma  of  the  cervix.  The  older 
methods,  such  as  induction  of  labour,  if  the  disease  is  recognized  in 
pregnancy,  and  the  dragging  of  the  child  past  the  growth  if  the 
condition  is  Been  for  the  firs!  time  during  labour,  are  unsound  in 
principle.  Induction  of  premature  labour  might  at  first  sight  ap] 
correct  enough  treatment,  hut  why  sacrifice  the  child,  or  run  the  risk 
of  doing  so?  It  is  much  better  to  allow  the  pregnancy  to  continue  to 
term  and  perform  Cesarean  Bection. 

Taking  first  of  all  the  cases  recognized  in  pregnancy,  one  should 
decide  whether  the  case  is  operable  or  inoperable.  If  operable, 
the  tumour,  with  the  necessary  portion  of  bowel  and  surrounding 
structures,  should  be  at  once  removed ;  while,  if  the  disease  is 
inoperable,  the  pregnancy  should  be  allowed  to  continue  up  to  or 
as  near  term  as  possible.  As  far  as  I  can  find,  Kjelberg's1  first  case 
is  the  only  one  in  which  the  tumour  was  removed  without  disturbing 
the  pregnancy,  which  had  reached  the  fourth  month.  Spontaneous 
labour  occurred  at  term.  The  modern  surgical  attitude  towards  car- 
cinoma affecting  the  uterus  is  to  remove,  not  only  the  uterus,  but 
also  the  cellular  tissue  around  the  uterus.  Is  it  therefore  sound 
surgically  to  simply  remove  the  rectal  growth,  and  allow  the  pregnant 
uterus  to  remain  ? 

It  is  just  possible  that,  owing  to  the  presence  of  the  enlarged 
uterus,  there  may  be  difficulty  sometimes  in  deciding  whether  or  not 
the  tumour  can  be  removed.  If  that  should  happen,  the  patient 
must  have  the  benefit  of  the  doubt.  If  need  be,  the  abdomen  must 
be  opened  and  the  uterus  turned  out.  The  condition  of  the  rectal 
growth  should  then  be  examined,  and,  if  operable,  the  pelvic  contents 
removed.  Should,  however,  the  malignant  disease  he  considered 
inoperable,  the  pregnant  uterus  is  replaced  in  the  abdomen  and  the 
pregnancy  allowed  to  continue. 

Some  may  think  that  allowing  the  pregnancy  to  continue  in 
inoperable  cases  is  inhuman,  and  so  should  I  if  the  woman's  suffer- 
ings were  great.  In  these  cases,  provided  opium  loses  its  effects, 
the  patients'  sufferings  will  usually  he  sufficiently  relieved  by 
performing  an  inguinal  colotomy,  as  Duncan  did  in  his  case.  The 
attitude  assumed  by  this  operator  appears  to  me  to  be  beyond  doubt 
most  sound. 

In  cases  of  rectal  carcinoma  recognized  during  labour  Cesarean  » 
section  is  a  much  sounder  treatment  than  pulling  the  child  past  the 
growth.     The   dragging   of   the   child   past    the   growth    has   proved 
i  Ref.  Zent ./'.  Qyn.,  1903,  p.  1076. 


TUMOUES  OF  THE  BLADDER  AN])  RECTUM  259 

disastrous  upon  several  occasions,'  as,  for  example,  in  the  cases 
recorded  by  Herman1  and  Cruveilhier.2  Quite  a  number  of  successful 
Cesarean  sections  have  been  performed  ;  and  even  in  Duncan's  case, 
where  an  inguinal  colotomy  had  been  performed  previously,  Cesarean 
section  was  most  satisfactory,  as  the  child  and  mother  were  both 
saved.  The  tumour,  if  operable,  may  be  dealt  with  at  the  same  time 
as  the  child  is  delivered ;  but  it  is  better  practice  to  allow  the  woman 
to  recover  from  the  confinement,  and  to  deal  with  the  rectum  a  week 
or  two  later. 

i  Lond.  Obst.  Trans.,  vol.  xx.,  p.  191. 

2  Ref.  Hollander,  op.  cit. 


CHAPTER  XVIII 

DYSTOCIA  THE  RESULT  OF  ABNORMALITIES  AFFECTING  THE 
PARTURIENT  CANAL—  Continued 

Suppurative  Conditions  in  Pelvis  and  Abdomen. 

Si  i  i  i  kative  conditions  connected  with  the  reproductive  and  other 
pelvic  organs  complicating  labour  are  more  frequent  than  is  generally 
supposed.  In  recent  years,  in  the  Glasgow  Maternity  Hospital  and  in 
private  practice,  I  have  had  several  cases  under  my  care. 

Vulva. — Of  abscesses  about  the  vulva,  those  connected  with  the 
glands  of  Bartholin  are  the  most  common.  I  have  seen  two  cases,  one 
of  which  died  of  acute  septicaemia.  The  other  recovered,  probably 
because  the  whole  tissue,  including  the  gland  and  surrounding  parts, 
was  removed  and  the  vulva  very  thoroughly  cleansed.  These  abscesses 
sometimes  contain  very  virulent  pus,  although  not  infrequently  the 
infecting  organism  is  the  gonococcus. 

Pelvic  Cellular  Tissue. — Some  little  time  ago  I  performed  a 
Cesarean  section  in  a  nursing  home  upon  a  woman  at  the  end  of 
her  second  pregnancy,  who  had  had  a  very  difficult  craniotomy  at 
her  previous  confinement  owing  to  the  smallness  of  her  pelvis. 
There  was  a  sinus  discharging  in  the  groin,  connected,  as  was  after- 
wards discovered,  with  the  spinal  column.  The  parts  about  the  thighs 
and  vulva  were  most  thoroughly  cleansed  and  isolated  from  the 
abdomen  by  means  of  wet  dressings  and  bandages.  The  operation 
was  performed  at  term  and  before  labour  had  started.  The  whole 
uterus  was  removed.  The  woman  made  a  most  satisfactory  recovery, 
but  from  the  seventh  to  the  seventeenth  day  there  was  slight 
febrile  disturbance.  Jardine  has  recorded  two  cases  of  retroperi- 
toneal abscess,  one  behind  the  kidney  and  the  other  behind  the 
caecum.  In  one  of  the  cases  rupture  occurred  into  the  peritoneal 
cavity,  and  in  both  the  women  died.  Freund  1  records  a  case  where 
at  the  sixth  parturition,  which  occurred  prematurely,  a  para- 
metric exudation,  which  had  developed  after  the  previous  labour,  burst, 

1  Ref.  YVertheun,  "Winckel's  'Handbuch  der  Geburtshulfe.'  Bd.  ii.,  Teil  i..  p.  491. 

260 


SUPPURATIVE  CONDITIONS  IN  PELVIS  AND  ABDOMEN   261 

and  was  followed  by  the  woman's  death.  Several  interesting  cases 
are  referred  to  by  Wertheim.1 

Tubes  and  Ovaries. — But  more  frequent  than  the  conditions 
described  are  those  in  which  the  suppurative  process  has  been 
connected  with  the  ovaries  and  tubes.  Quite  a  large  number  of  such 
cases  are  on  record.  Personally,  I  have  experience  of  two — one  in 
which  the  diagnosis  was  confirmed  at  the  post-mortem  examination ; 
the  other  in  which,  unfortunately,  there  was  no  examination  after 
death.  The  histories  of  both  cases  were  very  similar.  The  case 
in  which  the  diagnosis  was  confirmed  was  a  multipara  whom  I  saw  in 
consultation  with  Dr.  Gardner  Neill.  The  history  was  as  follows : 
Seven  days  before  she  had  been  delivered  without  any  difficulty  of 
a  living  child.  For  three  days  she  remained  well,  but  early  on  the 
fourth  the  temperature  rose  and  the  pulse  became  more  rapid. 
Abdominal  pain  also  developed.  When  I  saw  her  three  days  later 
she  was  extremely  ill,  with  very  rapid,  irregular  and  feeble  pulse,  and 
great  abdominal  distension.  She  was  evidently  dying,  and  too  feeble 
for  operation.  A  few  hours  after  I  saw  her  she  died.  At  the  post- 
mortem examination  there  was  general  peritonitis,  which  had  evidently 
arisen  from  an  abscess  connected  with  the  tube.  In  Jardine's2  case  the 
temperature  and  pulse  were  also  normal  until  the  third  day.  The  late 
Milne  Murray3  described  an  interesting  case  in  which  he  saved  the 
patient  by  laparotomy. 

The  pus  which  escapes  into  the  peritoneal  cavity  may  come  from 
the  fimbriated  ends  of  the  Fallopian  tubes  or  from  a  rupture  of  the 
sac.  In  some  cases  only  one  tube  is  affected,  as  in  Murray's  and  the 
one  I  have  just  described,  but  generally  both  tubes  are  involved. 

Short  of  actual  rupture  or  leakage  from  the  tubes,  the  latter  may 
become  injured.  I  removed  a  single  pyosalpinx  some  years  ago  in  the 
fourth  week  of  the  puerperium  from  a  woman  who  had  had  great 
abdominal  pain  since  her  confinement.  The  tube  was  very  vascular. 
She  made  an  excellent  recovery. 

Early  in  the  puerperium,  when  the  uterus  is  large  and  soft,  it  is 
not  easy  to  palpate  the  tubes,  and  once  or  twice  I  have  been  on  the 
point  of  opening  the  abdomen,  when  the  pain  and  fever  have  subsided 
with  regular  intra-uterine  douching.  Sudden  and  severe  abdominal 
pain,  with  steady  development  of  symptoms  of  general  peritonitis, 
must  immediately  be  dealt  with  by  abdominal  section.  After 
removal  of  the  sac,  the  question  of  vaginal  drainage  will  arise. 
While   I   am  quite  in  favour  of   such    drainage  under  ordinary  eir- 

1  Winckel's  '  Hanclbuch,'  Bd.  ii.,  Teil  i.,  p.  490. 

2  '  Clinical  Obstetrics,'  3rd  edition,  1910,  p.  515. 

3  Edin.  Obst.  Trans.,  vol.  xxv.,  1899-1900,  p.  38. 


262  OPERATIVE  MIDWIFERY 

oumstanees  in  general  septic  pelvic  peritonitis,  it  appears  to  me 
a  mistake  in  cases  early  in  the  puerperium,  for  the  discharge  in  the 

vagina  may  readily  infect  the  uterus.  Ordinary  drainage  through  the 
abdominal  wound  I  am  very  sceptical  about,  although  some  still  look 
upon  it  with  favour.  If  it  La  decided  to  drain,  I  think  it  best  to  make 
a  counter-opening  in  the  loin. 

Another  condition,  and  one  which  closely  simulates  pyosalpinx, 
i-  appendicitis.  In  the  cases  of  this  condition  which  1  have  seen, 
I  have  always  obtained  a  history  of  previous  attacks.  The  pain  was 
extreme  but  local,  and  quieted  down  with  rest  and  fomentations. 

Appendicitis  in  connexion  with  pregnancy  is  a  subject  which  has 
aroused  great  interest  amongst  obstetricians  and  surgeons  in  recent 
years,  and  this  is  not  to  be  wondered  at  considering  how  common  the 
condition  is.  Cuthbert  Lockyer  referred  to  the  subject  in  the  dis- 
cussion on  '  The  Appendix  and  Pelvic  Inflammation,'  which  took  place 
at  the  annual  meeting  of  the  British  Medical  Association  in  Toronto,1 
and  emphasized  very  strongly  the  dangers  of  the  condition  and  the 
advisability  of  operating  earl}'. 

Recent  contributions  to  the  subject,  such  as  Filth's,2  show  that  it  is 
a  condition  of  very  great  gravity,  and  that  unfortunately  it  is  often 
overlooked,  the  pain  complained  of  being  attributed  to  the  enlarging 
uterus.  A  most  useful  paper  is  one  by  Meyer,3  who  considers 
143  collected  cases.  He  comes  to  very  much  the  same  conclusions  as 
other  writers,  and  he  gives  interesting  statistics.  It  seems  to  be 
generally  admitted  that,  although  pregnancy  does  not  predispose  to  a 
primary  attack  of  appendicitis,  if  the  woman  is  subject  to  appendi- 
citis she  is  more  liable  to  have  recurrences  during  pregnane}*. 
There  is  also  greater  risk  of  abscess  formation.  In  all  probability 
this  is  largely  due  to  the  obstinate  constipation  of  pregnancy  and  the 
disturbance  produced  by  the  large  uterus.  In  the  cases  in  which  there 
is  no  abscess  formation,  pregnancy  is  rarely  disturbed  b}7  the  removal 
of  the  appendix.  In  the  suppurative  cases,  however,  abortion  or 
premature  labour  frequently  follows,  and  the  pregnant  woman  is  then 
in  special  danger  of  septicemia. 

As  can  be  readily  understood,  the  diagnosis  may  be  very  difficult 
indeed.  Suppose  the  woman  complains  of  a  little  pain  in  the  right 
iliac  fossa,  how  readily  one  may  attribute  it  to  the  disturbing  effect  of 
the  growing  uterus,  or  even  to  a  threatening  abortion.  Theoretically, 
the  condition  of  the  pulse  and  temperature  should  guide  one.  but  I 
need  hardly  remark  that  frequently  in  the  very  worst  cases,  where 

i  Brit.  Med.  Journ.,  1906,  vol.  i.,  p.  1709. 

2  Archiv  f.  <ii/>i.,  Bd.  Ixxvi.,  Heft  8,  p.  507. 

3  Ami  r  Jou/rn.  of  Obst.,  1906,  vol.  i. 


SUPPURATIVE  CONDITIONS  IN  PELVIS  AND  ABDOMEN  263 

there  is  an  extensive  collection  of  pus,  these  are  only  slightly  disturbed. 
Itigidity,  such  a  valuable  sign,  is  often  not  available,  owing  to  the 
presence  of  the  distended  uterus.  The  history  of  previous  attacks, 
and  the  fact  of  the  pain  being  localized  and  the  part  being  tender  to 
pressure,  and,  above  all,  the  appearance  of  the  woman  and  the  blood  - 
count,  must  be  one's  guides  when  there  is  little  disturbance  of  pulse 
or  temperature. 

Many  conditions  may  simulate,  or  be  simulated  by,  appendicitis — 
viz.,  ovarian  tumour  with  twisted  pedicle,  painful  myoma,  extra- 
uterine pregnancy.  But,  after  all,  mistakes  regarding  this  condition 
are  not  so  serious,  for  operation  is  generally  necessary  in  all  of  them. 

I  have  had  once  or  twice  under  my  care  patients  who  complained 
of  severe  uterine  pain,  but  in  whom  I  could  discover  absolutely  nothing 
abnormal.  The  pain  in  most  of  these  cases  was  diffuse.  As  the 
women  were  multipara?,  I  looked  upon  the  condition  as  being  the 
result  of  chronic  metritis.  Should  it  happen  that  the  pain  is  localized, 
as  in  one  of  my  cases,  the  diagnosis  is  extremely  difficult.  Fortunately, 
in  my  case  the  pain  was  left-sided. 

During  labour  a  chronic  appendicitis  may  be  lit  up,  or  an  old 
abscess  burst,  and  a  free  escape  of  pus  occur  into  the  general  peri- 
toneal cavity.  In  such  cases  the  severe  and  acute  pain  persisting 
even  during  the  intervals  between  the  uterine  contractions  would 
arouse  suspicion.  In  extreme  cases  the  condition  might  simulate 
rupture  of  the  uterus.  Zalachos1  records  two  cases  where  the  two 
conditions  coexisted. 

But  in  all  probability  the  greatest  diagnostic  difficulties  occur  in 
the  puerperium,  for  then  any  pain,  tenderness,  and  rise  in  pulse  and 
temperature  are  naturally  put  down  to  septic  infection  of  the  uterus. 
When,  however,  the  labour  has  not  been  severe,  and  there  has  been 
no  reason  for  sepsis  occurring,  and  especially  when  the  uterus  is  well 
retracted  and  the  os  firm  and  closed,  then  in  all  right-sided  iliac  pain 
one  should  think  of  appendicitis. 

All  writers,  without  exception,  are  agreed  that  the  same  surgical 
principles  should  guide  one  in  treating  a  case  of  appendicitis  in  the 
pregnant  as  in  the  non-pregnant. 

The  appendicitis  should  be  treated  and  the  uterus  left  severely 
alone.  If  abortion  or  labour  follows,  the  delivery  must,  of  course,  be 
completed,  every  possible  care  being  taken  to  prevent  infection  of  the 
uterus,  for  cases  of  this  nature  are  the  most  serious. 

The  condition  of  the  parturient  after  delivery  must  be  carefully 
watched,  and  the  abdomen  opened  if  it  is  deemed  necessary.     Should 
the  latter  become  imperative,  an  attempt  must  be  made  to  shut  off  the 
1  Epitome,  Brit.  Med.  Journ.,  November  11,  1905. 


264  OPERATIVE  Mll>Wll'Ki;Y 

vagina  and  vulva  as  far  as  possible  from  the  field  of  tin;  abdominal 
operation  by  carefully  packing  the  vagina.  Aiter  the  abdominal 
operation   is  completed,   the   vagina]   packing   should    be   removed. 

should  it  he  iitrt-sui  to  drain  tin-  abdominal  cavity,  it  Bhould  be 
done  through  a  counter-opening  in  the  loin. 

All  eases  occurring  in  the  puerperiuin  must  he  promptly  dealt 
with,  and  if  there  is  any  suspicion  of  abscess  formation  tin-  abdomen 
must  be  immediately  opened. 

The  recent  results  in  the  cases  associated  with  an  extensive  pufi 
formation  have,  as  I  have  already  said,  been  very  satisfactory.  Even 
some  of  the  cases  where  general  peritonitis  has  been  present,  ae  in 
the  most  interesting  one  described  by  Mauchlaire,1  have  resulted  in 
recovery. 

1   A  mini.  (lr  Qyn.t  190.";,  p.  '24:j. 


CHAPTER  XIX 

DYSTOCIA  THE  RESULT  OF  ABNORMALITIES  AFFECTING  THE 
PARTURIENT  CANAL— Continued 

Alterations  in  the  Axis  of  the  Canal— Displacements  Backward, 
Forward,  and  Downward  —  Displacements  the  Result  of 
Vaginal  and  Abdominal  Fixation  of  the  Uterus. 

Under  this  heading  of  alterations  in  the  axis  of  the  parturient  canal, 
several  very  interesting  conditions  call  for  consideration.  The  one 
which  naturally  occurs  to  one's  mind,  and  which  we  shall  first  discuss, 
is  backward  displacement  of  the  gravid  uterus.  In  addition  to  that, 
however,  there  is  the  forward  displacement  associated  with  a  pendulous 
abdomen,  and  the  alterations  in  the  uterine  axis  which  result  from 
ventral  and  vaginal  fixation. 

It  is  unnecessary,  I  think,  to  consider  here  the  lateral  deviations 
of  the  uterus  so  constantly  present  during  pregnancy,  and  so  generally 
directed  to  the  right,  for,  beyond  the  fact  that  they  favour  occasionally 
malpositions  and  malpresentation,  they  disturb  but  little  either  preg- 
nancy or  parturition.  The  late  Milne  Murray  made  an  interesting 
contribution  to  this  subject  some  years  ago.1 

Backward  Displacement  of  the  Gravid  Uterus. 

Of  all  the  displacements  of  the  gravid  uterus  this  one  is,  without 
doubt,  the  most  interesting.  It  is  also  the  one  most  frequently 
encountered.  Every  obstetrician  has  met  with  it  many  times,  and 
I  doubt  if  there  is  any  general  practitioner  of  experience  who  has 
not  had  experience  of  it.  The  subject,  therefore,  is  of  very  great 
importance  to  all  who  practise  obstetrics.  Of  special  interest  is  it  to 
us  in  this  country,  for  to  William  Hunter  belongs  the  honour  of 
having  been  the  first  to  consider  exhaustively  the  complication. 
Others  before  him,  Gregoire  in  France  and  Kilmann  in  Germany, 
for  example,  knew  of  the  condition  and  incidentally  referred  to  it,  but 

1  Edin.  Obst.  Trans.,  vol.  xxii.,  p  39. 
265 


266 


OPERATIVE  MIDWIFER1 


all  are  agreed  thai  Eunter  was  the  first  to  consider  it  in  detail. 
The  students  of  (llasgow  I  ni versify  should  take  particular  pride 
and  interest  in  the  matter,  for  the  Bpecimen — the  uterus  was  removed 
post  mortem — upon  which  Eonter  lectured  on  October  21,  1754,  is 
still  to  l)e  seen  in  all  its  beauty  in  the  Hunterian  Museum  of  our 
University.  Here  is  a  drawing  of  the  Bpecimen  (Pig.  126).  Hunter 
seems  to  have  taken  peculiar  pride  in  the  specimen,  for  it  is  seen 


Fig.  126. — Drawing  ol  Specimen  Is.  i"'s.  Bunterian  Museum,  Glasgow  University. 

The  specimen  was  obtained  from  the  ease  of  retroversion  of  the  gravid  uterus  which 
formed  the  text  of  Banter's  historic  lecture  on  the  subject. 


resting  upon  the  table  in  the  portrait  of  him  by  Sir  Joshua  Reynolds. 
The  history  of  the  specimen  appears  to  be  of  such  interest  as  to 
warrant  me  inserting  it  here,  especially  as  one  can  give  it  in  Hunters L 
own  words : 

'A  young  woman,  about  four  months  advanced  in  her  first  pregnancy, 
after  a   frighl    was   taken    ill,   an  I   CO  lid    not    with  nit    great    difficulty    go    I" 

1  'Medical  Observations  and  Enquiries  by  a  Society  of  Physicians  in  London.' 

'2nd  edition,  vol.  x..  p.   tOl. 


BACKWARD  DISPLACEMENT  OF  THE  GRAVID  UTERUS  267 

stool  or  make  water.     Her  complaint  grew  worse  daily,  till  on  Saturday, 

October  12,  both  these  evacuations  were  entirely  suppressed.  The  sup 
pression  of  urine  continued,  without  any  relief  being  given,  till  Thursday. 
the  17th,  when  Mr.  Walter  Wall,  surgeon,  was  called  to  her  assistance  lie 
drew  off  by  the  catheter  about  7  or  8  quarts  of  urine.  He  then  attempted 
to  throw  up  a  clyster;  but  very  little  passed  up,  and  it  had  no  manner  of 
effect.  In  the  afternoon  about  3  quarts  of  water  tinged  with  blood  were 
drawn  off  by  the  catheter. 

'  In  order  to  discover  the  cause  of  these  symptoms,  Mr.  Wall  introduced  a 
finger  into  the  vagina,  which  could  not  pass  up  on  account  of  a  large  tumour 
that  lay  behind  the  vagina,  and  pressed  it  close  to  the  inside  of  the  ossa 
pubis.  As  there  was  not  room  to  pass  the  finger,  he  could  neither  reach  the 
extremity  of  the  vagina  nor  could  he  discover  anything  like  the  os  uteri. 

'  After  this  he  examined  the  rectum,  and  found  that  the  same  tumour, 
which  lay  above  and  before  the  gut,  pressed  it  so  strongly  against  the  gut 
inside  of  the  os  coccygis,  etc.,  that  the  finger  could  only  be  passed  a  very 
little  way. 

'  These  circumstances  made  Mr.  Wall  recollect  a  case  of  retroverted 
uterus  which  M.  Gregoire  had  given  in  his  lectures  at  Paris.  He  then 
concluded  that  this  was  a  case  of  the  same  nature,  and  attempted  to  reduce 
the  uterus  by  laying  the  patient  on  her  back,  and  by  assisting  with  one 
finger  in  the  vagina  and  another  in  the  rectum,  as  M.  Gregoire  had  directed, 
but  without  any  success.  The  poor  woman  continuing  in  great  pain, 
Mr.  Wall  came  to  me  on  Saturday,  the  1 9th,  gave  me  an  account  of  what 
had  passed,  and  desired  me  to  visit  her  with  him.  We  found  her  exceedingly 
weak  and  suffering  great  pain.  She  was  lying  upon  her  back.  I  passed  my 
finger  between  the  tumour  and  the  inside  of  the  os  pubis,  a  little  to  one  side 
of  the  urethra,  upon  which  a  considerable  quantity  of  urine  was  discharged, 
as  my  finger  removed  the  pressure  upon  the  urethra.  We  then  proposed  a 
second  attempt  to  reduce  the  uterus  to  its  natural  situation,  for  which 
purpose  we  placed  her  upon  her  knees  and  elbows,  with  her  head  and 
shoulders  as  low  as  possible.  Then  I  introduced  one  hand  into  the  vagina 
and  two  fingers  of  the  other  hand  into  the  anus,  and  endeavoured  to  replace 
the  uterus  by  pushing  it  up  with  the  two  fingers,  and  at  the  same  time  by 
trying  to  draw  down  the  upper  part  of  the  vagina,  which  was  considerably 
retracted  from  its  natural  situation.  But  these  attempts  were  all  in  vain  ; 
she  became  weaker  every  hour,  and  died  on  the  Monday  following. 

'  On  Wednesday  we  were  allowed  to  open  the  body.  Upon  cutting  into 
the  abdomen  we  found  the  bladder  amazingly  distended  with  urine,  and 
filling  up  almost  the  whole  anterior  region  of  the  abdomen,  like  the  uterus  in 
the  last  months  of  pregnancy. 

'  When  urine  was  discharged  by  opening  the  bladder,  we  observed  that 
the  lower  part  of  the  bladder,  which  is  united  with  the  vagina  and  cervix 
uteri,  and  into  which  the  ureters  are  inserted,  was  raised  up  as  far  as  the 
brim  of  the  pelvis  by  a  large  round  tumour  (viz.,  the  uterus),  which  entirely 
filled  up  the  whole  cavity  of  the  pelvis.  We  then  passed  a  catheter  up  the 
vagina,  and  observed  that  it  raised  up  the  bladder  at  the  top  of  the  tumour — 
a  demonstration  that  the  upper  end  of  the  vagina,  and  consequently  the  os 


268  OPERATIC  E  MlhW  lli:i:Y 

uteri,  was  situated  there  ;  and  upon  making  a  crucial  incision  through  the 
bladder  and  vagina  at  that  place,  we  found  that  it  actually  was  so.  The  os 
uteri  made  the  Bummit  of  the  tumour  upon  which  the  bladder  rested,  and 
the  fundus  uteri  \\.i>  turned  down  towards  the  os  coccygis  and  anus.  The 
uterus  in  that  retroverted  state  was  grown  bo  large,  and  thence  so  wedged 
in  the  pelvis,  that  we  could  not  take  it  out  until  we  had  cut  through  the 
symphysis  of  the  ossa  pubis,  and  torn  these  bones  considerably  asunder  to 
enlarge  the  Bpace  within  the  bones  of  the  pelvis.' 

After  Hunter's  communication  the  subject  seems  to  have  given 
rise  to  a  great  deal  of  interest,  for  one  finds  in  the  '  Medical 
Observations  and  Inquiries,'  vol.  v.,  no  fewer  than  four  different 
communications.  In  addition,  there  seem  to  have  been  discussions 
regarding  it,  for  Hunter  speaks  of  '  the  very  existence  of  such  a 
disease  having  been  contradicted,  till  of  late,  at  least,  in  a  neighbouring 
enlightened  country.' 

Varieties  of  Backward  Displacement  of  the  Gravid  Uterus.— 
In  backward  displacement  of  the  uterus  in  the  non-pregnant  it  is 
customary  to  distinguish  two  varieties — viz.,  retroversion  and  retro- 
flexion ;  for,  although  the  two  have  much  in  common,  each  has  a 
significance  peculiarly  its  own.  If  this  distinction  is  admitted  to 
be  useful  and  desirable  in  the  non-pregnant,  should  it  not  also  be 
adopted  in  the  gravid '? 

In  writing  on  this  subject,  Leishman1  remarks:  'As  the  clinical 
history  of  the  two  classes  of  cases  is  essentially  different,  it  is  necessary 
that  a  clear  distinction  be  drawn  between  them.'  Such  was  the  attitude 
of  all  writers  in  the  middle  of  the  last  century,  as  may  be  seen  from 
the  descriptions  by  Burns.  Rigby,  and  others.  Towards  the  end  of 
the  century,  however,  less  importance  was  attached  to  the  matter, 
and  the  two  terms  were  employed  indiscriminately.  In  our  country 
retroversion  was,  and  still  is,  the  term  most  favoured — in  all  probability 
because  it  was  the  one  employed  by  Hunter.  The  same  also  applies 
to  France.  In  Germany,  on  the  other  hand,  retroflexion  is  the  one 
in  more  general  use.  Quite  recently,  however,  in  such  important 
monographs  as  those  of  Diihrssen-  and  Chrobak,3  the  essential 
differences  between  the  clinical  features  of  the  two  displacements 
have  been  again  emphasized. 

Not  content  with  the  broad  distinction  between  the  two  groups 
mentioned,  some  writers  have  subdivided  retroversion  into  three 
different  degrees — it  is  impossible  to  do  this  with  retroflexion.  This 
subdivision  of  retroversion  goes  back  to  Hunter's  time,  for  in  his  last 

1   '  System  of  Midwifery,1  2nd  edition,  p.  •27'.'. 
-  Archvof.  Gyn.,  Bd.  Ivii.,  1899. 
Samml.  Klin.  Vortrage,  No.  377,  1904. 


BACKWARD  DISPLACEMENT  OF  THE  GRAVID  UTERUS  269 

paper  on  the  subject,  published  in  1776  under  the  title  '  Summary 
Remarks  on  the  Retroverted  Uterus,'  he  says:  '  In  this  distressing  state 
the  uterus  may  be  (1)  fully  retroverted,  (2)  half  retroverted,  (3)  so  far 
in  its  natural  state  that  the  body  of  the  uterus  shall  be  downwards.' 

One  sees  from  this  division  how  carefully  Hunter  had  been 
observing  the  cases  that  had  come  under  his  notice ;  indeed,  so 
accurate  is  his  classification  that  it  practically  is  the  same  as  the 
one  given  in  the  monographs  already  mentioned.     Hunter,  however, 


Fig.  127. — Sacculation  and  Partial  Retroversion  of  the  Gravid  Uterus. 
(Dr.  W.  L.  Reid.) 


did  not  recognize  a  retroflexion,  although  Lynn  suggested  the  term  in 
the  case  he  reported. 

While  agreeing  in  the  main  with  the  contention  of  Diihrssen  and 
Chrobak,  that  the  two  varieties  are  distinct,  I  am  inclined  to  side  with 
Wertheim,1  who  thinks  the  distinction  more  of  theoretical  interest 
than  of  practical  importance.  It  is  perfectly  true  that  with  extreme 
retroversion  symptoms  appear  later,  and  the  replacement  of  the 
uterus  is  more  difficult  to  effect  than  when  the  organ  is  retroflexed 
or  only  half  retroverted.  The  essential  features  of  the  two  conditions- 
are  the  same,  however. 

1  Winckel's  '  Handbuch,'  Bd.  ii.,  Teil  i.,  1904. 


270  OPERATIVE  MIDWIFERY 

But  there  is  yei  another  variety,  and  in  some  respects  it  is  the 
most  interesting,  where  u  portion  of  tin;  uterus  remains  imprisoned 
in  the  pelvis,  while  the  anterior  and  upper  pari  o!  the  wall,  as  the 
organ  enlarges,  extends  into  the  abdomen.  It  has  been  variously 
described  as  'partial,'  ' incomplete,' and  'spurious*  retroflexion.  In 
recent  years,  however,  another  term  for  the  condition  has  come  to 
be  employed  —  viz.,  'sacculation'  of  the  uterus.  The  historical 
example  of  the  variety,  and  the  one  generally  quoted,  is  Oldham's,  , 
although  the  condition  was  known  long  before  Oldham  described  his 
case.  The  illustration  (Fig.  127)  given  here  is  from  a  case  described 
by  Dr.  W.  L.  Reid,1  of  Glasgow,  who  kindly  lent  me  the  block. 

Features  and  Progress  of  the  Condition. — As  has  been  already 
indicated,  the  condition  is  found  almost  without  exception  in  women 
who  have  suffered  from  a  backward  displacement.  It  is  stated  to  have 
followed  once  or  twice  some  fall  or  jerk  when  the  bladder  was  over- 
distended,  but  if  such  cases  have  occurred,  they  are  very  exceptional, 
as  the  overdistension  of  the  bladder  is  the  result,  not  the  cause,  of  the 
complication.  Very  occasionally  old  adhesions,  tumours,  deformities 
of  the  pelvis,  especially  undue  projection  of  the  promontory,  have 
been  found.     These  conditions  will  be  referred  to  later. 

At  first  the  condition  gives  rise  to  little  discomfort.  As  a  rule  the 
third  month  has  almost  been  completed,  and  the  uterus  has  become 
slightly  incarcerated,  before  any  symptoms  present  themselves.  This 
statement,  however,  must  be  qualified,  for  occasionally  reflex  dis- 
turbances, such  as  hyperemesis,  are  more  marked,  and  are  immediately 
relieved  if  the  displacement  is  recognized  and  corrected. 

It  is  the  bladder  which  suffers  in  retrodisplacement  of  the  uterus 
during  pregnancy,  for,  beyond  emptying  itself,  the  uterus  escapes  as 
a  rule.  The  first  evidence  of  the  displacement  is  in  most  cases  a 
difficulty  in  urination,  and,  indeed,  so  characteristic  of  the  condition 
is  this  symptom  that  dysuria  in  the  early  months  of  a  pregnancy 
should  alwrays  arouse  in  one's  mind  the  suspicion  of  backward  dis- 
placement. 

The  time  of  its  onset  is,  as  a  rule,  the  twelfth  to  the  fourteenth 
week,  but  the  size  of  the  uterus,  and  especially  the  variety  of  dis- 
placement, influences  this  not  a  little.  With  retroversion  of  the 
second  degree  and  retroflexion  difficulties  in  urination  appear  earlier 
than  with  extreme  retroversion.  In  these  latter  cases  the  fourteenth 
or  fifteenth  week,  or  even  later,  may  be  reached  before  symptoms 
manifest  themselves.  The  difficulty  in  urination,  at  first  slight, 
gradually  increases,  although  it  must  not  be  forgotten  that  occa- 
sionally it  may  come  on  quite  suddenly,  and  so  simulate  retention, 
1  Kdin.  Obst.  Trans.,  vol.  v.,  1879. 


BACKWARD  DISPLACEMENT  OF  THE  GRAVID  UTERUS  271 

the  result  of  an  acute  displacement.  Finally,  complete  retention  of 
urine  occurs,  or  sometimes  an  incontinence,  clue  to  an  overflow ;  and 
this  has  led  a  casual  observer  to  overlook  the  real  nature  of  the 
condition. 

Mechanical  pressure  upon  the  neck  of  the  bladder  by  the  displaced 
cervix  is  generally  given  as  the  reason  for  the  retention,  although,  at 
first,  the  latter  probably  results  from  ojdema  of  the  bladder  wall, 
produced  by  the  cervix  pressing  upon  the  veins  and  retarding  the 
circulation  about  the  neck  of  the  bladder.  Reed1  discusses  this 
matter  in  detail,  and  considers  it  due  chiefly  to  pressure  upon  the 
nerves  supplying  the  bladder. 

Several  writers,  including  Barnes,  describe  and  figure  the  bladder 
cavity  becoming  divided  by  the  cervix  into  two  unequal  parts.  This, 
however,  as  Duhrssen  points  out,  can  only  occur  in  cases  of  extreme 
retroversion.     I  have  certainly  observed  it  in  one  case. 

As  a  result  of  the  retention  of  urine,  the  bladder  becomes  enor- 
mously distended.  Its  wall  becomes  also  much  thickened  ;  in  one 
case,  at  which  I  assisted  Professor  Murdoch  Cameron,  the  wall  was 
as  thick  as  that  of  the  gravid  uterus.  In  part  this  increase  in 
thickness  is  a  true  hypertrophy,  but  to  a  considerable  extent,  owing 
to  pressure  upon  the  veins  about  the  neck  of  the  bladder,  the  wall  of 
the  latter  becomes  cedematous  and  more  or  less  extensively  necrosed. 
Portions  of  mucous  membrane,  sometimes  the  whole  mucous  mem- 
brane, and  occasionally,  in  exceptional  cases,  even  the  muscular  and 
peritoneal  coats  of  the  bladder,  become  separated  and  expelled  per 
urethram.  The  cases  of  this  nature  in  which  practically  the  whole 
bladder  wall  is  shed  are  of  extreme  interest.  In  the  English  language 
Haultain's  paper  is  very  complete  up  to  1890. 2  Since  then,  Duhrssen, 
Chrobak,  and  others,  have  referred  to  a  number  of  cases.  One  can 
understand  how  the  mucous  membrane  may  be  shed,  and  even  how 
a  layer  of  the  muscular  tissue  may  come  away,  but  how  the  whole 
muscular  and  even  the  greater  part  of  the  peritoneal  coat  may  become 
detached  is  more  difficult  of  comprehension.  Such  an  occurrence, 
however,  is  now  admitted  by  everyone.  In  the  cases  which  recover, 
a  new  receptacle  for  urine  forms. 

With  the  injuries  to  the  bladder  mentioned,  conditions  are  most 
favourable  for  the  invasion  of  septic  organisms,  with  the  result  that 
all  degrees  of  local  inflammation  follow,  and  neighbouring  structures 
and  organs  become  matted  together.  Although  this,  to  a  great  extent, 
forms  a  protection  against  a  general  peritoneal  infection,  it  may  very 
decidedly  prevent  reduction  of  the  uterus.     At  any  time  these  pro- 

1  Amer.  Journ.  of  Obst.,  1904,  vol.  xlix.,  p.  155. 
-  Edin.  Med.  Journ.,  June,  1890. 


272 


OPERATIVE   Mll'W  M-KliY 


tecting  adhesions  may  give  way  owing  to  the  growth  of  the  ovum  or 
as  a  result  of  artificial  attempts  at  n.luction.  A  general  peritonitis 
naturally  follows. 

llupture  of  the  bladder,  which  may  occur  spontaneously  or  may 
follow  manual   attempts  at  rectification,  is  the  most  serious  of  all 


Fig.  128. — Fatal  Septic  Cystitis,  with  Rupture  of  the  Bladder,  following  Retroversion 
of  the  Gravid  Uterus.     (Lloyd  Roberts.) 


accidents,  and  is  invariably  fatal.  Llo}-d  Roberts1  recently  recorded 
a  case,  the  illustration  of  which  he  has  kindly  allowed  me  to 
introduce   here   (Fig.   128).     Gottschalk,2  in   his   collected   series   of 

1  Jowrn.  Obst.  and  Qyn.  Brit.  Empire,  vol.  x.,  July,  1906,  p.  51. 
-  Archivf.  Gyv.,  1894,  Bd.  xlvii. 


BACKWARD  DISPLACEMENT  OE  THE  GRAVID   UTERUS  273 

seventy  cases,  found  it  occurred  eleven  times,  while  Berge,1  in  his 
collection  of  ninety  fatal  cases  of  incarceration  of  the  gravid  uterus, 
found  that  the  cause  of  death  proceeded  from  the  bladder  in 
80  per  cent. 

Following  the  overdistension  of  the  bladder,  the  necrosis  of  its 
walls,  and  the  infection  of  its  contents,  distension  and  infection  of  the 
ureters  and  kidneys — pyonephrosis  and  pyelitis — may  supervene. 

Aery  much  less  severe  than  the  urinary  complications  described 
are  disturbances  of  the  bowels.  Constipation  is  often  very  persistent, 
and  Dienst2  quite  recently  described  a  case  of  obstruction  of  the  bowel, 
but,  as  far  as  I  can  gather,  there  is  only  one  fatal  case  on  record,  that 
by  Treub,3  where,  at  the  post-mortem  examination,  the  compressed 
colon  was  found  gangrenous. 

A  still  rarer  complication  is  where  the  distended  uterus  has  been 
pushed  down  between  the  vagina  and  rectum,  and  finally  protrudes 
through  one  or  other  of  these  canals.  The  most  striking  example 
of  this  kind,  where  the  fundus  bulged  into  the  vagina,  is  recorded  by 
Grenser  and  quoted  by  Barnes.4  Halbertsma5  records  one  in  which 
the  uterus  caused  the  rectal  wall  to  bulge  through  the  anus.  The 
uterus  itself,  however,  did  not  bulge  through  the  anus,  as  some  writers 
have  stated. 

A  very  rare  occurrence  is  rupture  of  the  uterus;  Main6  has 
described  such  a  case. 

As  the  disease  advances  and  remains  untreated,  a  variety  of 
symptoms  appear,  such  as  rapid  pulse,  febrile  temperature,  furred 
tongue,  and,  shortly  before  death,  great  restlessness  and  delirium. 
These,  however,  are  for  the  most  part  the  results  of  septic  infection. 

So  far  as  we  have  considered  the  complication,  its  progress  has 
been  from  bad  to  worse.  But  while  such  is  the  course  run  by  many  of 
the  cases  which  come  under  observation,  there  is  a  very  large  number 
in  which  the  displaced  organ  spontaneously  rights  itself,  and  an 
equally  large  number,  probably,  in  which  abortion  occurs.  The  relative 
frequency  of  these  two  occurrences  is  difficult  to  estimate,  but  con- 
sidering how  common  backward  displacement  of  the  uterus  is,  and 
how  frequently  such  a  displacement  is  discovered  when  dealing  with 
cases  of  abortion,  one  is  justified  in  the  conclusion  that  each  of 
the  terminations,  spontaneous  rectification  and  abortion,  frequently 
happen.      A   most   interesting   paper   by  Herman7   deals   with    this 

1  Monat.  f.  Gel.  u.  Gyn.,  1901,  vol.  xiii.,  p.  812. 
-  Dent,  Med.  Woclu,  November  16,  1905. 

3  Journ.  Obst.  and  Gyn.  Brit.  Empire,  June,  1905. 

4  '  Obstetric  Operations,'  p.  222.  5  Monat.  f.  Geb.,  vol.  xxxiv.,  p.  414. 

6  Archiv  f.  Gyn.,  Bd.  lviii.,  p.  125.  7  Brit.  Med,  Jour?i.,  1904,  vol.  i.,  p.  877. 

18 


-7  1  <;i:atiyi:  midwifery 


i 


-  -  in  the  London  B  J85  tojj 

8  inclusive,  and  those  of  Champneg  3  tholome1  tall 

from  1881  1       392    there  were  11".  i  in  these  only! 

_  .     In  ti   -  Herman  llfcsi 

—  1  in  8  I  in  17.     Without  doubt,  when  tl. 

-  advanced  to  tl  •  symptoms   of   i: 

aboi  ot  nearly  so  frequent.     Am  •  it  writers  who  make! 

a  distinction  ;i  retroversion   and    retroflexion   it    is    gener 

agreed  that  with  both  abortion  is  liable  to  occur,  and  with  bot: 
in  the  ease  of  extreme  retroversion,  spontaneous  rectification  otv 
infinitely  more  frequently  than  incarceration. 

The  generally  acce]  .anation  of  spontaneous  rectification, 

which,  by  the  way,  rarely  occurs  after  any  manifestation  of  in 
tion,  is  that  the  uterus,  ..-  _-  the  retroflexed  part  out  of 

the  pelvis.     Under  strong  uterine  contractions  this  may  occur  suddenly, 
but    in    many  cases  it    is   a   gradual    pi     ■  --.     Contractions   of 
round  ligament  are  not  generally  accepted  as  having  much  to  do  with 
spontaneous  rectification. 

But  there  is  the  third  group,  in  which  a  portion  of  the  ute:  - 
left  behind  in  the  pelvis.  This  is  now  referred  to  as  partial  retro- 
flexion or  sacculation  of  the  gravid  uterus.  It  is  quite  possible  in 
certain  cases,  where,  for  example,  a  tumour  of  the  uterus  or  the 
ovary  exists,  that  the  retrodisplacement  is  really  secondary,  the 
tumour  preventing  the  uterus  from  extending  upwards  in  the  abdomen, 
but  in  other  cases  it  is  certainly  the  result  of  adhesions.  I  once 
saw  a  case  where  a  myoma  of  the  uterus  prevented  the  fundus  from 
rising  and  caused  sacculation,  while  a  fe  -  ago  a  c   -  sent 

to  me  where  a  broad-ligam  had  a  similar  effect.      Croom,1 

IHihrssen,2  and  others,  have  recorded  similar  cases.     As  examples 
sacculation,  the  result  of  a  portion  of  the  gravid  uterus  remaining 
behind,  mention  may  be  made  of  the  -eribed   by  Oldham,3 

Merriman,4  Barnes,5  Hicks.  Reid,6  and  Diihrssen.7 

A  case  of  very  great  interest  is  one  recorded  by  Macleod,8  where 
pregnancy  went  on  to  term  and  the  child  was  delivered  .ean 

ion.     When  the  abdomen  was  opened,  a  small  fibroid  • 
covered  in  the  anterior  uterine  wall,  and  the  fundus  could  not  be 
raised  because  of  the  adhesions  to  the  neighbouring  struct  . 

As  -:   :ed  before,  I  do  not  consider  that  it  serves  any  purp 

1  •  Clinical  Papers,'  1901,  p.  203.  " 

3  Lond.  Obst.  Trans.,  vol.  i..  p.  317. 

1  •  A  Synopsis  of  the  Various  Kinds  of  Difficult  Parturiti' 

.  eii.,  p.  ■-  Edin.  Obst.  Tr,.  -        vol.  v..  p.  56. 

j  .  •    '..  p.  T  ■  Brit.  Med.  Journ.,  1901.  vol.  i..  p.  I 


BACKWARD  DISPLACEMENT  OF  THE  GRAVID  UTERUS   275 

distinguish  between  sacculation  and  partial  retroflexion,  particularly 

as  the  features  of  both  are  in  all  essentials  the  same. 

Although  bladder  troubles  occur  with  sacculation,  they  are  seldom 
so  extreme,  and  there  is  never  the  extensive  destruction  of  the  bladder 
walls  which  is  so  common  an  occurrence  in  the  ordinary  varieties 
of  displacement.  Abortion  is  common,  but  in  not  a  few  pregnancy 
has  continued  to  term. 

Diagnosis.  —  The  diagnosis  of  retrodisplacement  of  the  gravid 
uterus  is  not.  as  a  rule,  difficult.  Prior  to  incarceration  there  are 
generally  no  symptoms  whatever,  although  on  passing  the  examining 
linger  into  the  vagina  a  large  swelling  is  felt,  and  the  vaginal  canal 
is  found  to  run  directly  upwards  behind  the  symphysis.  High  up, 
sometimes  higher  than  the  finger  can  reach,  is  the  cervix.  A  bimanual 
examination  reveals  the  absence  of  the  uterine  body  in  front,  ami 
presence  in  Douglas'  pouch  behind.  Suppression  of  menstruation, 
alteration  in  the  breasts,  etc..  and  enlargement  of  the  uterus,  decide 
one  in  favour  of  pregnancy,  in  addition  to  a  backward  displacement. 
It  is  unnecessary  to  explain  that  tumours  of  the  ovary,  myomata. 
and  harmatocele  may  simulate  or  be  simulated  by  a  retrodisplaced 
uterus,  and  that  each  of  these  conditions,  especially  if  there  is  a 
coexisting  pregnancy,  is  only  to  be  determined  by  a  careful  con- 
sideration of  the  case  in  all  its  aspects,  and,  above  all,  by  a  most 
careful  bimanual  examination. 

Later,  when  symptoms  of  incarceration  exist,  and  especially  if 
they  have  existed  for  some  time,  and  the  bladder  wall  has  become 
much  thickened,  exact  palpation  of  the  pelvic  and  lower  abdominal 
contents  becomes  most  difficult.  All  are  familiar  with  the  error  of 
mistaking  a  distended  bladder  for  a  tumour,  and  the  simple  means  of 
preventing  such  an  occurrence — viz.,  emptying  the  bladder  by  catheter. 
But  in  cases  in  which  difficulty  in  urination  has  existed  for  some  time, 
even  after  the  bladder  has  been  emptied  and  retracted,  so  thick  are 
the  walls  of  the  latter  that  the  organ  can  sometimes  be  felt  above  the 
symphysis,  just  like  a  uterus  gravid  to  the  third  or  fourth  month; 
thus  the  retracted  bladder  may  be  mistaken  for  the  gravid  uterus,  and 
the  swelling  in  Douglas'  pouch — the  gravid  uterus — for  an  ovarian 
or  myomatous  tumour.  Such  an  error  is  made  evident  by  passing 
a  sound  into  the  bladder  and  feeling  it  through  the  abdominal  wall, 
high  up,  inside  the  swelling,  that  projects  above  the  symphysis. 

There  is  a  feature  invariably  present,  and  one  which  seldom 
exists  to  any  extent  in  other  conditions  simulating  incarceration  of 
the  retrodisplaced  gravid  uterus,  and  that  is  the  great  difficulty, 
often  the  inability,  to  pass  urine.  As  far  as  I  have  seen,  no  tumour, 
be  it  uterine  or  ovarian,  incarcerated  in  the  pelvis  and  pressing  upon 


276  OPERATIVE   Mll>\YIIT.l;Y 

the  bladder  and  aterae  ever  gives  rise  to  such  extreme  and  persistent 
difficulty  <>f  micturition  as  does  the  incarcerated  retrodisplaced  litems. 
Certainly  I  have  seen  both  ovarian  cysts  and  myomata  of  the  uta 
causing  urinary  trouble,  once  or  twice  to  the  extent  of  requiring 
catheterization,  but  never  the  persistenl  obstruction  one  finds  with 
the  complication  at  present  under  discussion. 

There  is  one  other  condition  which,  occasionally,  very  closely 
resembles  retroversion  of  the  gravid  uterus  —  viz.,  extra-uterine 
pregnancy,  especially  if  the  sac  has  ruptured  and  there  is  a  pelvic 
hematocele.  Curiously  enough,  in  this  condition  also  there  is  often 
some  difficulty  in  micturition,  although  it  is  never  so  extreme  as  in 
retrodisplacement.     Here  is  a  case  which  was  under  my  care  : 

Extra-Uterine  Pregnancy  simulating:  a  Retroflexion  of  the 

Gravid  Uterus. 

J.  C ,  aged  thirt}r,  3-para,  was  admitted  to  the   Western  Infirmary 

under  my  care  on  March  LI,  1898. 

The  patient  complained  of  pain  in  the  right  side  and  difficulty  of 
micturition  and  defalcation  of  four  weeks'  duration.  She  had  had  two 
children,  the  last  eight  years  before.  Menstruation  had  always  been  regular 
since  the  age  of  fifteen.  Her  last  period  was  on  November  12.  About  four 
weeks  prior  to  admission  she  began  to  have  pain  in  the  lower  part  of  her 
abdomen.  A  week  later  she  took  to  bed,  where  she  remained  until  trans- 
ferred to  hospital.  While  confined  to  bed,  she  had  considerable  difficulty  in 
passing  urine  and  very  obstinate  constipation. 

On  bimanual  examination,  the  cervix  was  found  pressed  against  the 
symphysis  pubis  and  higher  than  normal.  This  was  caused  by  a  large 
tumour  filling  up  the  pouch  of  Douglas  and  extending  slightly  above  the 
brim.  There  seemed  to  be  a  certain  amount  of  mobility  in  the  tumour.  <  >n 
careful  palpation,  the  anterior  wall  of  the  uterus  seemed  to  lie  continuous 
with  the  upper  part  of  the  tumour,  and  the  posterior  lip  of  the  cervix  with 
the  lowermost  part. 

I  had  no  hesitation  in  making  the  diagnosis  of  retroflexion  of  a  gravid 
uterus,  a  diagnosis  that  the  patient's  medical  attendant  had  made  before 
sending  her  to  hospital.  Attempts  at  replacement  under  chloroform  were 
made,  but  although  the  tumour  could  be  raised,  it  was  impossible  to  get  it 
completely  above  the  promontory  of  the  sacrum. 

For  some  days  after  these  manipulations  there  was  bleeding  and  pain  in 
the  lower  part  of  the  abdomen.  These  symptoms,  however,  disappeared 
with  rest  and  morphia  suppositories.  Ten  days  later  she  was  again  carefully 
examined  under  chloroform,  when  I  began  to  be  doubtful  about  the  corn 
ness  of  the  diagnosis.  The  condition  of  the  parts  was  exactly  the  same  as 
on  her  admission. 

On  the  day  following  the  second  examination,  Professor  M.  Cameron 
having  returned,  we  saw  the  case  together,  and  he  quite  agreed  that  it  had 
all  the  appearances  of  retroflexion  of  the  gravid  uterus.     As,  however,  the 


BACKWARD  DISPLACEMENT  OF  THE  GRAVID  UTERUS  277 

patient's  condition  was  not  satisfactory,  lie  advised  passing  the  sound,  which 
was  done.  It  passed  into  the  uterus  about  3  inches  in  the  normal  direction. 
The  case  was  therefore  cleared  up.  The  following  day  the  abdomen  was 
opened,  and  a  large  sac  of  an  extra  uterine  pregnancy  moulded  to  the 
posterior  wall  of  the  uterus  removed.  It  was  adherent  to  the  surrounding 
parts,  and  was  situated  exactly  in  the  middle  line  deep  in  the  pouch  of 
Douglas.  The  pregnancy  had  advanced  to  almost  the  fourth  month,  to  judge 
by  the  foetus  contained  in  the  sac. 

Many  examples  of  this  mistake  have  been  described.  Most  of  the 
text-books  on  midwifery  mention  it,  and  not  a  few  monographs  and 
communications  to  various  societies  exist  on  the  subject.  For 
example,  Giles1  records  two  cases,  while  Barbour2  has  made  two 
communications  on  the  subject.  The  more  recent  monographs  of 
Diihrssen,  Chrobak,  and  Wertheim,  all  refer  to  it  in  some  detail. 

As  illustrating  the  danger  of  a  mistaken  diagnosis,  mention  may 
be  made  of  the  case  reported  by  Van  der  Haeven.3  The  woman  was 
a  primipara  three  months  pregnant,  where  a  diagnosis  of  retroversion 
of  the  gravid  uterus  was  made.  After  the  tumour  in  Douglas'  pouch 
was  apparently  replaced,  profound  collapse  came  on  and  a  retro-uterine 
hematocele  formed,  evidently  from  rupture  of  a  gravid  tube.  An 
error  of  the  opposite  nature  is  a  case  recorded  by  Asterblum,4  where 
the  pouch  of  Douglas,  and  then  the  retroiiexed  uterus  gravid  to  four 
months,  were  opened,  in  the  belief  that  the  condition  was  a  hematocele. 
Death  followed  from  sepsis.  When  the  abdomen  was  examined  post 
mortem,  an  inflammatory  exudation  covered  the  retrofiexed  uterus. 

Undoubtedly,  the  diagnosis  between  the  two  conditions  is  often 
difficult.  Indeed,  judging  by  the  reported  cases,  the  symptoms  may 
be  almost  exactly  similar.  The  fact,  however,  that  with  extra-uterine 
pregnancy  one  usually  gets  a  history  of  attacks  of  pain  and  of 
irregular  discharges  of  blood,  that  the  retention  of  urine  is  seldom 
so  complete,  that  the  contour  of  the  sac  is  less  uniformly  smooth,  and 
that  the  cervix  is  seldom  so  much  displaced  upwards,  will  usually 
clear  up  the  diagnosis. 

Barnes5  lays  special  stress  on  the  position  of  the  cervix.  He 
says :  '  One  general  fact  of  great  service  in  forming  a  diagnosis 
is  this — almost  all  bodies  which  get  into  Douglas'  pouch  come 
from  above,  and  so  push  the  uterus,  not  only  forwards,  but  at  the 
same  time  downwards,  thus  bringing  the  os  uteri  within  easy  reach 
and  pointing  downwards.  On  the  other  hand,  retroversion  of  the 
uterus    lifts    the    os    upwards    and    tends    to  throw    it    forwards.' 

1  Lond.  Obst.  Trans.,  vol.  xxxix.         -  Trans.  Edin.  Obst.  Soc,  vol.  xix.,  p.  156. 

:!  Epitome  No.  318,  Brit.  Med.  Journ.,  1898,  vol.  i. 

4  Zent.  f.  Gyn.,  1905,  p.  154.  5  Op.  cit,  p.  226. 


278  OPERATD  E  MIDWIFERY 

Theoretically  that  may  be  correct,  but  in  practice  it  is  aot  alwayt 
as  witness  Barbour's  case,  where  the  cervix  was  'above  reach,' and 
the  case  I  have  reported,  where  it  was  distinctly  higher  than  usual. 
The  irregular  discharges  of  blood,  so  helpful  in  the  differential 
diagnosis,  as  pointed  out  1>\  Barbour,  are  not  always  present,  as  in 
my  case  they  occurred  only  after  manipulative  attempts  at  replace- 
ment. On  the  other  hand,  in  retroflexion  they  may  occur  if  abortion 
threatens,  as  was  illustrated  by  a  rase  recently  under  my  care. 

In  the  case  of  partial  retroflexion  or  sacculation,  the  diagnosis  is 
often  extremely  difficult,  and  the  records  of  almost  all  the  cases  already 
referred  to  show  this.  Indeed,  in  a  number  the  true  state  of  matters 
was  only  appreciated  when  the  finger  was  introduced  into  the  uterus. 
Besides,  in  many  cases  a  tumour  was  also  present.  "What  adds  to  the 
difficulty  is  the  fact  that  the  sacculation  is  often  cedematous,  and  so 
simulates  a  tumour  of  ovary  or  uterus.  Undouhtedly,  in  some  few- 
cases  the  foetal  head  has  heen  felt  through  the  thinned-out  wall, 
hut  this  was  not  so  in  Reid's  case  (Fig.  127),  for  the  placenta  was 
implanted  in  the  sacculation. 

Advanced  extra-uterine  pregnancy  is  stated  to  simulate  the  con- 
dition of  sacculation,  although  in  neither  of  the  two  cases  of  the 
condition  which  I  have  seen  was  there  any  very  marked  projection 
of  the  tumour  into  the  pelvis.  There  are,  of  course,  exceptions,  as 
in  Phillips'1  case,  but  in  a  very  large  number  of  recorded  cases  of 
advanced  ectopic  pregnancy  which  I  have  consulted  projection  of  the 
sac  into  the  pelvis  has  not  heen  a  feature. 

It  is  obvious,  therefore,  that  no  rule  can  be  laid  down  for  guidance 
in  such  cases.  This,  however,  may  be  said,  that  a  consideration  of 
the  history  and  a  careful  examination,  repeated  if  necessary,  will 
usually  result  in  a  correct  appreciation  of  the  nature  of  the  condition. 

Treatment. — Before  discussing  the  treatment  of  cases  in  which 
the  retrodisplaced  gravid  uterus  has  hecome  incarcerated,  it  is  well 
that  we  consider  for  a  moment  the  means  that  should  he  adopted  to 
prevent  the  occurrence  of  this  complication. 

As  retrodisplacement  of  the  uterus,  without  doubt,  is  occasionally 
a  harrier  to  pregnancy,  there  is  much  to  he  said  in  favour  of  correcting 
all  cases  of  backward  displacement  in  the  married  prior  to  the  meno- 
pause, even  although  no  symptoms  are  present.  Whatever  view  one 
takes  as  regards  that  matter,  all  are  agreed  that,  whenever  a  dis- 
placement is  discovered  during  pregnancy,  it  should  be  corrected, 
particularly  if  the  case  is  one  of  extreme  retroversion.  In  most  cases 
such  rectification  is  easy,  and  can  he  carried  out  by  pressing  the 
fundus  upwards  from  the  vagina.     In  a  certain  number,  however — and 

1  Obst.  Tnms,  1900,  vol.  xlii..  p.  121. 


BACKWARD  DISPLACEMENT  OF  THE  GRAVID  DTERUS    279 

I  had  one  of  the  kind  recently  under  my  care — the  uterus  cannot  he 
replaced  by  such  means,  even  although  it  is  not  fixed  by  adhesions 
behind.  Under  such  circumstances,  the  other  means  at  our  disposal, 
which  we  shall  consider  later,  may  be  tried,  or  the  patient  may  be  kepi 
in  bed  and  spontaneous  rectification  allowed  to  occur.  If  the  latter 
coarse  is  pursued,  an  examination  should  be  made  from  time  to  time, 
and  a  little  pressure  exerted  upon  the  fundus.  It  must  be  remembered, 
however,  that  examples  of  extreme  retroversion  are  not  suited  for 
such  expectant  treatment.  After  the  uterus  is  replaced,  a  vulcanite 
pessary  of  the  Hodge  or  Albert  Smith  form  should  be  inserted  into 
the  vagina,  and  retained  there  until  about  the  fourteenth  or  fifteenth 
week.  By  that  time  the  uterus  has  become  so  enlarged  that  the 
pessary  may  be  safely  removed  without  any  risk  of  the  uterus  falling 
back  into  the  hollow  of  the  sacrum.  In  the  early  weeks  of  pregnancy, 
while  the  pessary  is  being  worn,  the  patient  should  be  very  careful, 
and  I  always  put  such  patients  to  bed  at  the  times  which  would  have 
been  menstrual  periods  had  pregnancy  not  existed. 

Whenever,  upon  examination,  one  finds  a  retrodisplacement  pre- 
senting features  of  incarceration,  replacement  naturally  becomes 
imperative.  It  must,  however,  be  remembered,  in  the  treatment  of 
this  condition,  what  has  been  frequently  remarked  regarding  its 
symptomatology,  that  attention  to  the  bladder  is  everything.  So 
important  is  this  that  in  many  cases,  if  the  patient  is  put  to  bed  and 
the  bladder  kept  empty  by  catheter,  the  malposition  of  the  uterus  will 
correct  itself.  It  is  therefore  my  rule  to  keep  the  bladder  empty  for 
a  day  or  two  before  making  any  attempt  at  replacing  the  uterus,  if 
there  has  been  any  great  urinary  difficulty.  Particularly  should  this 
rule  be  followed  if  there  are  evidences  of  cystitis  and  extensive 
necrosis  of  the  bladder  wall,  for  during  forcible  attempts  at  replace- 
ment, under  such  circumstances,  rupture  of  the  bladder  has  occurred 
on  several  occasions. 

It  has  occasionally  happened  that  difficulty  has  been  experienced 
in  passing  the  catheter,  but  if  a  gum-elastic  one  is  used  that  is  never 
serious,  so  that  suprapubic  puncture  of  the  bladder  need  not  be  con- 
sidered. There  are,  of  course,  cases  where  there  is  difficulty  in 
withdrawing  the  urine,  owing  to  the  necrosed  portions  of  bladder  wall 
blocking  up  the  catheter.     Such  cases  we  shall  consider  immediately. 

When  cystitis  exists,  the  bladder  should  be  regularly  irrigated 
with  a  weak  saline  solution.  In  the  extremely  severe  cases,  where 
there  is  a  large  quantity  of  blood-clot,  necrosed  bladder  wall,  and 
stinking  urine,  much  more  radical  treatment  becomes  necessary,  or 
the  debris  cannot  be  washed  out.  The  bladder  must  be  emptied, 
therefore,  through   the  dilated  urethra,   or  if   that  is  impossible  it 


280  OPERATIVE   Mil  >\\  I  PERU 

must  be  opened  int. i.     The  former  proceeding  is  not  much  favoun 
for,  under  the  circumstances,  n  Bafficient  dilatation  of  the  urethra  is 
hardly  possible.     One  is  left,  therefore,  to  choose  between  making  the 
<>l>cninur  from  above  or  from  below.     Sinclair  and  Pinard  have  recorded 
cases  iii  which  the  bladder  was  opened  and  washed  out  from  below.    A 
most  interesting  case  ie  recorded  by  Cameron,1  where  the  bladder  v 
opened  into  from  ahove,  all  blood-clot  and    debris    cleared  out.  and  1 
finally  stitched,  after  which  the  uterus  was  replaced  and  the  abdoi 
closed.     The  patient  not  only  recovered,  but  pregnancy  was  uninter- 
rupted, and  she  was  delivered  of  a  living  child  at  term. 

Having  attended  to  the  bladder  in  the  manner  indicated,  one  is  in 
a  position  to  attempt  replacement  of  the  uterus.  In  mosl  of  the  cases 
simple  manual  manipulations  are  all  that  is  necessary.  After  having 
placed  the  patient  in  the  knee-elbow  position,  or,  what  i-  equally 
efficacious,  the  Sims  position,  two  fingers  are  passed  into  the  vagina. 
and  steady  pressure  exerted  upon  the  fundus.  The  advantage  of  the 
Sims  position  is  that  it  does  not  preclude  the  administration  of  an 
anaesthetic,  while  attempts  at  replacement  are  being  made. 

"When  pushing  up  the  uterus  in  order  to  avoid  the  promontory, 
pressure  should  be  made  more  to  one  side,  and  preferably  to  the  right 
of  the  pelvis,  for  the  fundus  is  most  commonly  directed  to  that  side, 
and  there  is  a  little  more  room  there.  I  do  not  favour  carrying  out 
the  manipulations  from  the  rectum,  as  Hunter  suggested  and  a  few 
operators  have  since  advocated,  notably  Herman,2  who  claims  that  one 
can  exert  pressure  higher  up.  If,  after  several  attempts,  success  does 
not  follow,  one  should  desist,  and  leave  the  patient  for  twenty-four 
hours,  as  there  are  many  cases  on  record  where,  after  fruitless 
attempts  at  manual  replacement,  the  organ  has  spontaneously  righted 
itself.     Here  is  an  example  from  my  own  practice : 

Incarcerated    Retroflexed    Gravid    Uterus  which    after  Several 
Fruitless  Attempts  at  Replacement  righted  Itself. 

H.  H ,  aged  thirty-one,  3-para,  came  under  my  car.'  at  the  Western 

Infirmary,  Glasgow,  in  August,  1894.  She  stated  she  was  about  four  months 
pregnant.  She  complained  of  great  pain  in  the  abdomen  and  difficulty  of 
micturition,  witli  an  almost  constant  dribbling  of  urine,  of  about  four  weeks' 
duration.  Her  first  pregnancy  was  normal  in  every  respect,  but  her  last,  in 
1887,  terminated  in  a  miscarriage  at  the  third  month,  she  last  menstruated 
on  April  28,  just  about  four  months  before  her  admission  to  hospital.  The 
symptoms  of  dysuria,  etc.,  came  on,  therefore,  at  the  end  of  the  third  month 
of  the  pregnancy. 

On  examination,  the  abdomen  was  much  distended  and  tender  to  pressure. 

1  Brit.  Mr,l.  Jaunt..  Octoher  ">1.  ls'.lti 
-  Ibid.,  1904,  vol.  i.,  p.  *77. 


BACKWARD  DISPLACEMENT  OF  THE  GKAVID  UTEBUS    281 

The  bladder  being  emptied  (GO  ounces  of  mine  were  drawn  off),  the 
distension  and  tenderness  of  the  abdomen  disappeared.  On  bimanual 
examination,  the  cervix  was  found  raised  and  pressed  against  the  symphysis 
pubis  by  the  very  much  enlarged  body,  situated  in  Douglas'  pouch.  The 
diagnosis  of  retroflexion  of  the  gravid  uterus  made  by  her  medical  attendant 
prior  to  admission  was  confirmed.  Attempts  were  made  to  replace  the 
organ,  but  failed,  even  when  she  was  placed  in  the  genu-pectoral  position. 
1  therefore  advised  the  house-surgeon  to  keep  the  bladder  empty  by  passing 
the  catheter  every  eight  hours,  to  see  that  the  bowels  were  thoroughly 
emptied,  and  to  prepare  the  patient  for  chloroform  on  the  following  day, 
when  further  attempts  would  be  made  to  rectify  the  displacement.  The 
woman  was  told  to  lie  well  round  on  her  face,  and  to  sometimes  assume 
the  genu-pectoral  position.  After  my  attempts  at  replacement  she  ex- 
pressed herself  as  feeling  much  relieved,  and  she  was  able  to  pass  urine 
quite  freely  a  few  hours  after.  On  examination  the  following  morning, 
prior  to  giving  her  chloroform,  great  was  my  surprise  to  find  the  uterus  in 
normal  position.     .She  was  dismissed  a  few  days  later  feeling  perfectly  well. 

When,  after  repeated  attempts  at  short  intervals,  manual  reposition 
proves  unsuccessful,  there  are  several  manoeuvres  which  should  be 
tried.  Amongst  the  simplest  is  pulling  down  the  cervix  with  volsellum 
forceps  while  pressure  is  exerted  upon  the  fundus  by  the  fingers 
(Fig.  129).  I  have,  however,  always  found,  and  other  operators  have 
had  a  similar  experience,  that  the  cervix  of  the  gravid  uterus  very 
readily  tears,  and  that  one  cannot,  therefore,  put  much  traction  upon 
it ;  besides,  one  often  cannot  reach  the  cervix.  Much  better  is  the 
device  of  employing  a  colpeurynter  distended  with  water  or  quicksilver, 
as  Albert1  and  Funke  have  advocated.  The  safest  way  of  employing 
the  colpeurynter  is  to  leave  it  distended  in  the  vagina,  and  allow 
the  steady  pressure  of  it  to  gradually  push  up  the  fundus.  One  can, 
however — and,  if  I  mistake  not,  Olshausen  advocates  the  method — 
place  the  colpeurynter  in  the  vagina  and  distend  it  while  the  patient 
is  in  the  lithotomy  position,  and  then  allow  the  legs  to  fall  down  as  in 
the  Walcher  position. 

A  similar  device,  recommended  by  Sinclair2  and  others,  is  the 
employment  of  a  watch-spring  pessary  of  such  a  size  that  when  intro- 
duced into  the  vagina  it  maintains  an  oval  shape,  and  so  exerts  a 
steady  and  constant  pressure  upon  the  displaced  fundus.  It  is  quite 
obvious  that  the  colpeurynter  or  watch-spring  pessary  can  only  be 
employed  if  there  is  room  in  the  vagina.  In  Sinclair's  most  interesting 
case  this  could  only  be  attained  after  the  bladder  had  been  cleared 
of  the  debris  it  contained,  and  the  cervix  had  been  pulled  down  by 
volsellum  forceps. 

1  Miinch.  Med.  Woch.,  1903,  No.  12. 
Trans.  Lond.  Obst.  Soc,  vol.  xlii. ,  p.  338. 


282 


OPERATIVE   MlhWIl'KllY 


Such  arc  the  devices  to  be  tried  for  the  correction  of  an  incarcerate. 1 
retrodisplaced  gravid  uterus.  Tiny  almost  invariably  Bucceed,  and, 
indeed,  Borne  operators  go  the  length  of  Baying  that  they  never  fail. 
Siu-li  a  position,  however,  is  too  extreme.  It  is  certainly  very  striking 
that  many  accoucheurs  <»f  wide  experience  have  never  encountered  a 
case  of  irredncible  retrodisplacement  of  the  gravid  uterus,  a  fact  which 
should  always  lead  one  to  pause  before  pronouncing  the  displacement 


Fig.  129.— Replacement  of  Incarcerated  Retroflexed  Uterus.     [After  Bumm.) 

irreducible,  and  to  question  the  judgment  of  such  an  operator  as 
Jacobs,  who  has  described  twelve  cases  in  which  he  had  to  perform 
abdominal  section. 

Admitting,  then,  that  although  rare  cases  are  now  and  then 
encountered  in  which  replacement  by  the  ordinary  methods  already 
described  is  impossible,  let  us  consider  for  a  moment  the  means  at 
our  disposal  for  treating  such  very  troublesome  cases. 

There  are  two  courses  open  to  one  in  dealing  with  cases  of  irre- 


BACKWARD  DISPLACEMENT  OF  THE  GRAVID  UTERUS 

ducible  retrodisplacement  of  the  gravid  uterus  ;  one  is  to  empty  the 
uterus  from  below,  and  the  other  to  open  the  abdominal  cavity  and 
replace  the  uterus  by  pulling  the  fundus  up  while  an  assistant  pushes 
it  from  the  vagina. 

The  former  alternative  was  the  only  method  employed  until  recent 
years,  and  induction  of  abortion  by  passing  a  sound  or  elastic  bougie 
was  the  proceeding  most  favoured.  But  in  not  a  few  cases,  particu- 
larly if  the  condition  was  one  of  retroversion,  it  was  found  impossible 
to  introduce  the  instrument.  In  such  cases  puncture  of  the  uterus 
from  the  vagina  or  rectum  was  recommended,  and  as  recently  as  188ft 
we  find  Barnes  writing : x  '  If  it  be  found  impossible  to  pass  an  instru- 
ment through  the  os  uteri,  if  induction  be  also  impossible,  and  the 
symptoms  urgent,  it  is  justifiable  to  puncture  the  uterus  by  the  vagina 
or  rectum.'  Barnes  preferred  puncture  from  the  rectum.  He  says  : 
'  The  rectum  is  to  be  preferred,  because  puncture  there  is  more  certain 
to  tap  the  body  of  the  uterus  and  to  keep  clear  of  the  cervix.'  Some 
years  later  Sanger2  suggested  incision  and  emptying  the  uterus  from  the 
vagina,  and  this  proceeding  was  successfully  carried  out  quite  recently 
by  Wennerstrom.3  Olshausen,  in  a  case  in  which  the  uterus  was  irredu- 
cible because  of  pelvic  deformity,  removed  the  whole  organ  per  vaginam. 

In  recent  years,  however,  the  possibility  of  replacing  the  uterus 
from  the  abdomen  without  sacrificing  the  child  has  become  more 
evident  every  day.  Laparotomy  for  the  condition  under  consideration 
was  suggested  years  ago.  Burns,  for  example,  in  the  tenth  edition  of 
his  text-book,  published  in  1863,  writes  (p.  298)  :  '  It  has  also  been 
asked  whether  it  would  not  be  allowable  to  make  an  incision  into  the 
abdomen  and  push  up  the  uterus.  Section  of  the  symphysis  has 
also  been  proposed.'  The  latter  treatment — symphysiotomy — has 
been  suggested  from  time  to  time,  and  is  of  special  interest,  for  it  will 
be  remembered  in  Hunter's  historical  case  that,  at  the  post-mortem 
examination,  it  was  only  after  the  symphysis  was  divided  that  the 
displaced  uterus  could  be  raised  from  the  pelvis. 

The  successful  results  obtained  by  laparotonry  have  brought  that 
treatment  more  and  more  into  favour,  and  many  cases  are  now  on 
record.  One  of  the  earliest  was  Cameron's,  already  referred  to. 
Jacobs,4  Mann,5  MacLean,6  Mouchet,7  and  Handfield  Jones,8  are  a  few 

1  Op.  cit,  p.  228.  -  Zent.  f.  Gyn.,  1894,  p.  175. 

3  Zent.  f.  Gyn. ,  1903,  p.  302. 

*  Joum.  d' Accouchement,  April,  1898  ;  and  Epitome,  Brit.  Med.  Journ.,  June  4, 
1898. 

5  A, tier.  Journ.  Obst.,  July,  1898.  fi  Ibid.,  August,  1898. 

7  Annal.  de  Gyn.  et  d'Obst.,  December,  1901. 

5  Journ.  Obst.  and  Gyn.  Brit.  Empire,  October,  1903. 


284 


OPERATIC  E  MII)\\ll'i:i;V 


operators  who  have  recorded  cases  so  treated    I  ig.  L80  ■     Jacobs  has 

operated  upon  as  many  as  twelve  cases,  and  in  four  of  these  he  found 
adhesions  of  the  litem-  to  Burrounding  tissues.     Handfield  .lone-' 
is  of  special  interest,  for  lie  found  the  adhesions  so  intimate  that 
owing  to  the  patient-  collapsed  condition  he  could  not  proceed  to  their 
complete  separation. 


Fig.  130. --Incarceration  of  the  Retrofiexed  Uterus.      After  Wertheim. 

In  front  the  Madder  is  being  dragged  forward,  thua  permitting  tin-  uteri  - 

J)i>tinct  adhesions  can  be  Been  on  the  posterior  surface  of  the  uterus. 


Here,  perhaps,  it  is  well  to  mention  that  adhesions  between 
fundus  and  surrounding  tissues  may  be  primary  and  the  cause  of 
the  displacement,  or  secondary  and  the  result  of  inflammation  follow- 
ing septic  infection  from  the  bladder.  In  the  former  the  adhesions 
will  probably  be  very  difficult,  and  sometimes  impossible,  to  break 


BACKWARD  DISPLACEMENT  OF  THE  GRAVID  UTERI'S  285 

down,  as  in  Macleod's  case,  but  in  the  latter  they  will  readily  give 
way.  In  a  few  no  adhesions  existed.  In  a  number  where  tumours 
were  the  cause,  the  removal  of  the  latter  allowed  of  replacement. 
The  following  case,  which  occurred  in  my  practice,  illustrates  this 
(Fig.  131)  : 

Incarceration  of  the  Retroflexed  Gravid  Uterus  with  Broad 
Ligament  Cyst— Laparotomy — Removal  of  Cyst — Replace- 
ment of  Uterus — Continuance  of  Pregnancy. 

The  patient,  a  fairly  robust  multipara,  aged  twenty-seven,  was  sent  to  me 
by  Dr.  Armstrong,  of  Kirkintilloch.    She  had  had  one  child  three  years  before. 


Fig.  131. — Retroflexion  of  Uterus  caused  by  Large  Broad  Ligament  Cyst.     (Author's  Case.)> 

The  retractors  are  holding  apart  the  edges  of  the  abdominal  wound  while  the  hand  is 
pulling  the  cyst  over,  thus  permitting  the  retroflexed  uterus  being  seen. 

The  period  prior  to  her  present  pregnancy  was  about  December  27,  1903. 
I  saw  her  first  on  April  28,  1904,  when  she  told  me  that  for  six  weeks  she 
had  been  troubled  with  her  urine — during  four  with  frequency  of  micturition, 
but  during  the  last  two  with  retention.  For  two  days  Dr.  Armstrong  drew 
off  the  urine  with  catheter.  Diagnosing  the  condition  as  an  incarcerated 
retroflexed  gravid  uterus,  he  sent  her  to  me.  I  examined  her  under  chloro- 
form with  him,  and  agreed  that  such  was  the  condition,  and  that  the  cause 


286  OPERATD  E   Ml  l>\\  I  IT.KY 

was  probably  a  tuiiH.ur  preventing  the  uterus  from  rising  up.  <  m.  May  l, 
1  opened  the  abdomen,  and  removed  with  Bome  difficulty  a  cystic  tumour 
about  th<'  size  of  a  foetal  bead  from  the  lefl  broad  ligament.     1  then  pushed 

up  the  uterus  fr the  vagina.     The  patienl   made  an  excellent  recovery, 

and  the  pregnancy  was  undisturbed  until  seven  and  a  half  months  were 
reached.  The  difficulty  in  micturition,  which  disappeared  after  the  operation, 
returned  slightly  for  a  week  or  two  before  delivery.  She  was  delivered  of 
a  small  seven  and  a  half  months  child  withoul  trouble. 

1 1  is  specialty  pleasing  and  encouraging  that  in  a  large  number  of! 
cases  not  only  was  the  uterus  replaced,  but  pregnancy  continued.  In 
all  Jacobs'  cases  except  one  pregnancy  continued;  this  also  happened 
in  the  cases  recorded  by  Cameron,  Mouchet,  Mann,  and  myself.  In 
operating  upon  such  cases,  steady  pressure  from  the  vagina  by  an 
assistant  is  of  the  greatest  help,  and  there  is  no  don  lit  that  it  is  an 
advantage  to  place  the  patient  in  the  Trendelenburg  position. 

If,  in  spite  of  such  devices,  I  still  found  it  impossible  to  raise  the 
uterus,  I  would  seize  the  organ  with  volsellum  forceps,  and  try  to 
get  my  fingers  down  behind  the  fundus,  not  only  for  the  purpose  of 
breaking  down  adhesions,  but  to  allow  air  to  get  into  the  pouch  of 
Douglas.  Should  it  still  be  impossible,  I  would  perform  Cesarean 
section,  empty  the  uterus,  stitch  it  up,  and  perform  ventro-fixation. 

But  a  word  must  be  said  regarding  those  rare  cases  of  sacculation 
of  the  gravid  uterus  in  which  the  pregnancy  continues  to  term, 
llecently,  as  we  have  already  seen,  Macleod  had  to  perform  abdominal 
section  for  such  a  condition,  and  naturally  such  a  proceeding  is  the 
onty  course  open  to  one,  if  the  sacculation  cannot  be  removed  or  the 
child  extracted.  As  Merriman  and  others  have  shown,  however, 
the  uterine  contractions  of  labour  are  sometimes  sufficient  to  remove 
the  sacculation,  and  in  Reid's  case  delivery  was  completed  by  bringing 
down  a  leg. 

Sometimes  the  sacculation  may  be  removed  by  pulling  the 
abdominal  portion  of  the  uterus  downwards  and  forwards,  and  push- 
ing the  sacculation  upwards  and  backwards.  Olshausen  and  Barnes 
record  successes  after  such  manipulations. 

If  laparotomy  is  necessary,  one  should  only  proceed  to  Csesarean 
section  if  there  are  other  indications  for  that  operation,  or  if  one 
failed,  as  did  Macleod,  to  pull  up  the  sacculation.  If  the  sacculation 
can  be  relieved,  it  appears  to  me  desirable  that  the  child  be  delivered, 
if  possible,  per  vias  naturales,  although  it  might  be  considered  wiser 
to  perform  Cesarean  section  if  the  uterus  was  the  seat  of  myomatous 
tumours,  and  if  the  condition  of  the  patient  was  such  that  a 
Cesarean  section  would  disturb  her  less  than  a  prolonged  labour. 


FORWARD  DISPLACEMENT  OF  THE   UTERUS         287 

Forward  Displacement  of  the  Uterus  during-  Pregnancy  and 

Labour. 

All  are  aware  that  a  feature  of  the  early  weeks  of  pregnancy,  and 
one  which  sometimes  assists  the  obstetrician  in  coming  to  a  diagnosis 
of  pregnancy  in  doubtful  cases,  is  an  increased  degree  of  anteflexion. 
The  reason  for  this  occurrence  is  the  increased  weight  of  the  fundus 
and  the  softening  of  the  tissues  at  the  upper  part  of  the  cervix.  As  a 
result  of  this  increase  of  normal  flexion  and  version,  frequency  of 
micturition  results  in  not  a  few  cases  ;  indeed,  in  the  early  weeks  of 
pregnancy  it  is  a  very  general  complaint.  There  should  never  be, 
however,  any  confusion  of  such  a  system  with  ischuria  paradoxica, 
which,  as  we  have  seen,  is  a  feature  of  the  incarcerated  retrodisplaced 
uterus  ;  for,  if  the  story  of  the  patient  leaves  any  doubt,  a  careful 
•examination  of  the  condition  of  the  pelvic  organ  will  clear  up  any 
obscurity.  In  addition  to  this  '  irritability  of  the  bladder,'  constipation 
may  be  aggravated,  although  I  have  never  seen  it  more  pronounced 
than  one  ordinarily  finds  it  during  pregnancy. 

Another  feature  emphasized  by  G-raily  Hewitt  and  others  is  an 
aggravation  of  the  sickness  of  the  early  weeks.  Without  attaching 
too  much  importance  to  anteflexion  as  a  cause  of  hyperemesis,  I  must 
admit  that  on  several  occasions  I  have  seen  the  latter  condition 
associated  with  an  undue  forward  displacement  of  the  uterus.  It 
might  only  be  a  coincidence,  but  it  has  been  too  frequently  remarked 
by  others  to  justify  such  an  explanation.  Besides,  I  have  seen 
the  sickness  relieved,  and  only  relieved,  by  correcting  the  displace- 
ment. There  is  no  evidence  that  an  undue  forward  displacement 
is  associated  with  a  tendency  to  abortion,  but  pelvic  uneasiness,  aching 
over  the  symphysis  and  down  the  thighs,  and  difficulty  in  locomotion, 
are  features  that  have  occasionally  been  found  associated  with  the 
malposition. 

The  diagnosis  of  the  condition  of  exaggerated  anteflexion  or 
anteversion  —  it  is  unnecessary  to  distinguish  between  the  two, 
although  they  both  occur — is  not  difficult.  On  vaginal  examination, 
the  cervix  is  discovered  tilted  back  and  higher  in  the  pelvis  than 
usual-  sometimes  very  markedly  so — while  at  the  same  time  the 
fundus  is  unusually  low.  On  bimanual  examination,  it  is  readily 
made  out  that  the  swelling  in  part  is  the  elastic  anteflexed  uterus. 
Occasionally,  I  must  admit,  it  has  felt  very  much  like  a  myoma  in  the 
anterior  uterine  wall,  but  a  myoma  is  harder. 

Incarceration  of  the  antedisplaced  uterus  is  never  of  any  serious 
moment ;  indeed,  it  is  questionable  if,  properly  speaking,  it  can  occur. 
'.Should  symptoms  arise,  and  it  is  believed  that  the  displacement  is 


288  OPERATIVE  BilDWIFERl 

the  cause,  occasional  pushing  up  ol  the  fundus,  with  the  patient  in 
the  dorsal  decubitus  and  the  pelvis  raised,  and  a  tampon  or  col- 
peurynter,  have  proved  successful. 

Later  in  pregnancy  all  are  familiar  with  the  falling  forwards  of 
the  uterus   in   cases   where   the   anterior   abdominal   wall   is  much 

weakened,  where  the  uterine  cavity  i-  unusually  distended,  and  where 
the  vertebral  column  and  pelvis  are  deformed  by  disease. 

The  cases  with  which  we  are  really  concerned  here  are  those 
in  which  the  anterior  abdominal  wall  is  at  fault.  A  pendulous 
abdomen,  especially  amongst  multiparous  women  of  the  working 
class,  is  not  uncommon.  This  condition  allows  the  uterus  to  project 
forwards  and  hang  over  the  symphysis  when  the  woman  is  in  the 
erect  position.  The  most  marked  examples  of  tho  condition  are 
found  associated  with  distinct  separation  of  the  recti  muscles.  The 
worst  case  of  the  kind  that  has  come  under  my  care  was  where  the 
cicatrix  of  an  abdominal  wound  had  given  way.  The  displacement 
was  so  extreme  that  the  uterus  hung  down  over  the  patient's  tin 
when  she  stood  up,  while,  on  vaginal  examination,  the  cervix  could 
hardly  be  reached. 

Eosner1  has  described  a  case  where  the  gravid  uterus  became 
incarcerated  in  a  ventral  hernia.  Abdominal  section,  and  then 
Cesarean  section,  were  necessary.  The  uterus  was  finally  removed, 
because  there  was  complete  occlusion  of  the  os  externum. 

Extreme  anteflexion  of  the  uterus,  besides  being  a  source  of  great 
discomfort  to  the  patient  during  the  later  weeks  of  pregnancy,  may 
be  the  cause  of  considerable  trouble  in  parturition.  Malpresentations, 
especially  breech  and  footling  presentations,  are  very  common.  The 
uterine  axis  during  labour  being  altered,  and  the  resistance  of  the 
abdominal  wall  being  lost,  labour  is  retarded  until  the  firm  support  of 
a  binder  is  supplied.  It  is  a  great  mistake  to  attempt  to  employ  the 
left  lateral  position  in  these  cases,  as  the  heavy  uterus  falls  over  and 
the  presenting  part  is  prevented  from  engaging.  This  is  especially  the 
case  if  forceps  is  employed.  The  patient  should  be  made  to  assume 
the  dorsal  decubitus  throughout  the  labour.  During  the  puerperium, 
also,  anteflexion  occasionally  prevents  the  escape  of  the  lochia,  and  a 
condition  arises  sometimes  termed  lochiometra.  I  have  only  once 
seen  a  typical  example  of  this  condition.  "When  I  removed  the  ante- 
flexion and  passed  in  an  intra-uterine  douche-tube,  I  was  surprised  at 
the  quantity  of  pent-up  lochia  which  escaped. 

The  treatment  of  the  condition  is  obvious — a  firm  abdominal  belt. 
The  material  to  be  used  is  of  no  great  importance,  although  a  broad 

i  Zent.f.  Gyn.,  1904,  p.  I486. 


PROLAPSE  OF  THE  UTERIS  2s«> 

strip  of  flannel,  over  which  is  applied  an  elastic  binder,  is  probably 

the  best. 

ft  will  often  be  found  in  such  cases  as  we  are  considering, 
especially  amongst  women  of  the  poorer  classes,  that  there  is  con- 
siderable irritation  of  the  skin  over  the  lower  part  of  the  abdomen  and 
pubes,  owing  to  chafing  between  the  two  surfaces.  This  is  a  distinct 
source  of  danger  to  the  patient,  for  the  irritated  areas  and  the  skin 
about  the  pubes  harbour  innumerable  micro-organisms.  Every  pre- 
caution must  therefore  be  taken  to  cleanse  the  part,  and,  if  possible, 
have  the  raw  surfaces  healed  before  labour  comes  on. 

Prolapse  of  the  Uterus. 

Prolapse  of  the  pregnant  uterus  is  sometimes  observed  in  multi- 
paras who  have  suffered  from  prolapse  for  some  time.  The  most 
extreme  case  of  the  kind  which  has  come  under  my  observation  was 
an  elderly  multipara,  four  months  pregnant,  who,  after  some  slight 
strain,  had  a  complete  procidentia  of  the  gravid  uterus,  associated 
with  complete  urinary  obstruction.  On  emptying  the  bladder,  the 
uterus  was  easily  replaced,  and  maintained  in  position  with  the  help 
of  a  pessary. 

Slighter  degrees  of  the  displacement,  where  the  os  uteri  has 
appeared  or  even  projected  beyond  the  vulvar  orifice,  I  have,  on  a 
few  occasions,  observed,  and  in  these  cases  there  was  generally  also 
difficulty  in  micturition. 

As  far  as  I  can  find,  there  is  no  case  on  record  in  which  pregnancy 
has  continued  until  term  in  a  uterus  completely  outside  the  vagina, 
but  there  are  one  or  two  recorded  where  a  considerable  portion  of  the 
uterus,  with  limbs  of  the  contained  foetus,  have  projected  behind  the 
external  orifice. 

The  older  writers  frequently  referred  to  acute  prolapse  during 
labour.  Mauriceau  and  Smellie,  for  example,  refer  to  such  cases ; 
recent  writers,  however,  rarely  do  so. 

I  have  once  or  twice  seen  the  presenting  head  covered  with  the 
undilated  cervix  just  within  the  vulvar  orifice,  and  during  extraction 
with  forceps  have  even  found  the  edges  of  the  cervix  appear  outside. 
A  case  such  as  Jentzen's,1  where  there  projected  a  portion  of  the  head 
completely  covered  with  the  thinned-out  cervix,  is  extremely  rare.  In 
that  particular  case  the  author  incised  the  cervix  and  delivered  a  dead 
child  with  forceps.  The  patient  was  a  primipara,  and  he  states  that 
before  labour  there  was  neither  prolapse  nor  hypertrophy  of  the  cervix. 

Naturally,  the  condition  that  is  most  likely  to  be  mistaken  for 
prolapse  of  the  uterus  is  hypertrophy  of  the  cervix,  and,  as  a  matter 

1  Arch,  de  Tocol,  Paris,  1890,  vol.  xvi.,  p.  268. 

19 


290  OPERATIVE  .Ml  l>\\  II'KltV 

of  fact,  the  two  conditions  often  coexist.  Confusion  is  esp<  -cialM 
liable  to  arise  if  acute  odema  of  the  cervix  occurs.  This  condition, 
which  has  been  referred  to  recently  by   several  writers,   is   considered 

in  Chapter  XIII. 

The  treatment  of  prolapse  of  the  uterus  is  to  replace  the  organ, 
and  maintain  it  in  position,  if  need  be,  by  means  of  a  support.     If, 

however,  the  ordinary  support— namely,  ;i  vulcanite  or  watch-spring 
pessary — is  not  sufficient,  the  patient  should  be  kept  in  bed  until 
the  uterus  is  of  such  a  size  that  it  can  no  longer  fall  down.  The 
replacement  of  the  prolapsed  uterus  is  seldom  difficult.  It  might,  I 
however,  happen  that,  owing  to  adhesions  or  a  tumour,  replacement 
is  impossihie,  and  although  1  am  not  aware  of  any  such  case.  I  see 
no  reason  why  it  might  not  occur,  seeing  that  an  irreducible  prolapse 
in  the  non-gravid  has  been  more  than  once  described,  for  example, 
one  recorded  by  Barbour  Simpson.1  In  the  event  of  such  a  condi- 
tion, two  courses  would  naturally  be  open  to  one — namely,  to  empty 
the  uterus  or  to  perform  abdominal  section  and  remove  the  condition 
producing  the  prolapse.  By  adopting  the  latter  means,  one  would 
hope  that  the  pregnancy  might  continue. 

The  cases  in  which  there  has  been  difficulty  in  reducing  the 
prolapse  have  invariably  been  successfully  treated  by  keeping  the 
patient  in  bed  and  emptying  the  bladder  at  regular  intervals,  and, 
from  time  to  time,  pushing  the  cervix  and  lower  part  of  the  body 
upwards,  for  in  these  cases  difficulty  in  replacement  arises  partly  from 
the  overdistension  of  the  bladder,  and  partly  from  the  a-dematous 
condition  of  the  cervix. 

Displacements  of  Uterus  the  Result  of  Vaginal  and  Abdominal 

Fixation. 

In  recent  years  many  operations  have  been  devised  for  correcting 
backward  and  downward  displacement  of  the  uterus.  The  three  most 
important  have  been  shortening  of  the  round  ligaments  (Alexander- 
Adam  operation) ;  incising  the  vaginal  wall,  pushing  aside  the  bladder, 
and  fixing  the  anterior  wall  of  uterus  to  the  vaginal  wound  (vaginal 
fixation) ;  opening  the  abdomen  and  fixing  the  uterus  to  the  anterior 
abdominal  wall  (hysteropexy  or  abdominal  or  ventral  fixation).  With 
the  relative  merits  of  these  different  methods  we  are  not  concerned, 
except  in  so  far  as  they  affect,  disturb,  or  complicate  subsequent 
pregnancies  and  parturitions.  The  one  which  undoubtedly  does  this 
least — in  fact,  I  have  never  heard  of  it  causing  any  trouble  whatever 
— is  the  '  Alexander-Adam  operation.' 

1  Edin.  Obst.  Trans.,  1904-05,  vol.  xxx.,  p.  94. 


DYSTOCIA  FROM  VAGINAL  FIXATION 


•291 


(t)uite  otherwise  is  it  with  '  vaginal  fixation,'  an  operation  which 
has  been  practised  but  little  in  this  country,  but  which  was  for  some 
time  much  favoured  in  Germany.  After  the  introduction  of  the 
operation,  some  twenty  years  ago,  it  was  universally  advocated.    Very 


Fig.  132. — Showing  the  Distortion  of  the  Gravid  Uterus  which  may  result  from 
Abdominal  Fixation.     (Edgar.) 

The  arrow  points  to  the  adhesion  between  uterus  and  abdominal  wall.     I  had  a  case  recently 
almost  similar.      The  adhesions  to  the  abdominal  wall  were  more  intimate. 


soon,  however,  it  was  found  that  parturition  was  often  very  difficult, 
and  that  even  Cesarean  section  was  sometimes  necessary  as  a  result 


292  OPERATIVE  Ml  I»W1I'KI;Y 

of  the  operation.  Some  few  yearn  ago  we  had,  in  the  Glasgow 
Maternity  Hospital.  an  illustration  of  the  extreme  dystocia  that 
mighl  result  from  vaginal  fixation.     A  patient  upon  whom  the  opera- 

tion  had  been  performed  by  one  of  our  staff  was  brought  into  hospital 

in  labour.  On  admission,  the  os  was  found  displaced  upwards  and 
backwards.  As  it  dilated,  the  presenting  part  refused  to  engage,  and 
a  leg  was  with  difficulty  brought  down.  As  it  was  still  found  impos- 
sible to  deliver  the  child,  the  operator  performed  Cesarean  section. 

Similar  cases  have  been  recorded  by  Strassrnan,  Martin,  Wertheim, 
and  others.  In  recent  years,  however,  since  it  was  appreciated  that 
the  dystocia  in  great  part  resulted  from  passing  the  ligatures  too  high 
up  on  the  uterine  wall,  one  reads  of  few  cases  of  difficulty.  In 
Stahler's  case,1  in  which  great  dystocia  followed  a  low  fixation,  it 
must  be  remembered  that  at  the  time  of  the  vaginal  fixation  two 
myomata  were  enucleated  from  the  body  of  the  uterus,  and  conse- 
quently the  adhesions  to  the  tissues  in  front  were  very  intimate.  Both 
Martin  and  Diihrssen,  in  their  recent  writings,  state  that  no  dystocia 
follows  a  low  stitching  of  the  uterus  (vesical  fixation). 

The  effect  of  hysteropexy  or  ventral  fixation  of  the  uterus  on 
subsequent  pregnancy  and  labour  is  a  matter  which  is  causing  a  good 
deal  of  interest  amongst  obstetricians  at  the  present  time.  The 
matter  is  still  sub  judice,  but  it  must  be  admitted,  I  think,  that 
dystocia  results  somewhat  more  frequently  than  was  at  first  imagined. 
There  are  now  many  contributions  to  the  subject,  and  several  writers 
in  addition  have  collected  and  analysed  the  recorded  cases.  Noble, 
in  1896,  discussed  the  subject  from  206  collected  cases,  while  recently 
Andrews-  did  the  same  from  395  cases  which  he  had  gathered  from 
English,  American,  French,  German,  and  Italian  literature.  The 
paper  of  the  latter  is  a  very  useful  one,  for  it  contains  not  only  a  table 
of  the  cases,  but  also  a  very  full  bibliography. 

The  following  are  Andrews'  conclusions  : 

1.  Ventral  fixation  may  be  the  cause  of  great  difficulties  in  labour. 

2.  These  difficulties  are  due  to  too  rigid  fixation  of  the  uterus. 
Eigid  fixation  of  the  anterior  wall  is  not  followed  by  so  much  difficulty 
as  is  fixation  of  the  fundus  or  posterior  wall. 

3.  The  method  of  fixation  involving  least  difficulty  in  labour  is 
that  in  which  the  uterus  is  attached  only  to  the  parietal  peritoneum, 
or  peritoneum  and  subperitoneal  connective  tissue. 

4.  In  women  who  may  become  pregnant  after  the  operation  it  ia 
not  advisable  to  anchor  the  fundus  or  posterior  wall  of  the  uterus 
by  firm  adhesions,  such  as  would  be  useful  in  cases  of  prolapse  in 

1  Zent.f.  dun.,  1902,  p.  176. 

2  Journ.  Obst.  and  Gyn.  Brit.  Empire,  190.3,  vol.  viii..  p.  97. 


DYSTOCIA  FROM  ABDOMINAL  FIXATION  ±m 

older  women ;  in  other  words,  '  suspension '  should  be  performed  in 
women  who  may  subsequently  become  pregnant,  fixation  in  older 
women. 

Since  Andrews'  paper  several  important  contributions  have  ap- 
peared— one  by  Seegert,1  and  two  in  English,  by  Herman2  and  Giles.:{ 
Herman  states  (p.  11):  'If  the  operation  is  properly  performed, 
subsequent  difficulty  in  labour  need  not  be  feared  ;  by  "  properly 
performed "  I  mean  that  the  anterior  half  of  the  fundus  uteri  is 
stitched  to  the  muscle  about  half-way  between  the  symphysis  pubis 
and  the  umbilicus.' 

I  am  specially  interested  in  Herman's  remarks,  as  I  have  for 
several  years  performed  hysteropexy  in  the  manner  he  describes, 
although  I  have  not  been  in  the  habit  of  stitching  the  fundus  quite 
so  high.  Up  to  the  present  I  have  had  one  case  of  such  very  decided 
dystocia  that  I  was  compelled  to  perform  Cesarean  section.4  In  two 
of  the  cases  abortion  occurred,  but  later  they,  in  common  with  the 
others,  carried  children  to  full  time.  One  of  the  patients  complained 
of  very  great  pain  during  the  early  months  of  pregnancy. 

Giles'  method  of  operating  is  more  simple.  Three  silk-worm  gut 
sutures  are  passed  through  the  whole  thickness  of  the  abdominal  wall, 
then  through  the  anterior  wall  of  the  uterus,  and  out  through  the 
abdominal  wall  on  the  other  side.  He  says  :  '  It  is  advisable  that  the 
sutures  be  passed  low  down  in  the  anterior  uterine  wall  in  women  of 
child-bearing  age.'  In  his  cases  twelve  became  pregnant,  five  mis- 
carried, seven  went  to  term,  and  of  these  latter  five  had  normal 
confinements  and  two  were  delivered  with  forceps. 

Amongst  the  cases  of  dystocia  may  be  mentioned  those  of  Clark 
and  Lee5  and  Caiman.6  Cameron  and  Hocheisen7  described  a  case 
of  dystocia  at  the  Gesellschaft  fur  Geburtshiilfe  und  Gynsekologie ; 
and  Bumm,  Nagel,  Olshausen,  Brose,  all  referred  to  difficulties  that 
they  had  experienced. 

It  is  perfectly  evident,  therefore,  that  ventral  fixation  may  occa- 
sionally cause  dystocia.  Roughly,  somewhere  about  1*5  per  cent, 
represents  the  frequency. 

1  Festschrift  f.  Olshausen,  1905. 

2  Journ.  Obst.  and  Gyn.  Brit.  Empire,  January,  1906. 

3  Brit.  Med.  Journ.,  vol.  ii.,  1906,  p.  1188. 

4  In  this  case  the  abdomen  was  twice  opened  before  the  Cesarean  section  was 
performed. 

5  Johns  Hopkins  Hospital,  1905,  p.  168. 

6  Zent.f.  Gyn.,  1906,  No.  6.  7  Ibid.,  1906,  No.  31,  p.  80. 


<  ii  \iTi:i;  x\ 

DYSTOCIA  THE  RESULT   OF   ABNORMALITIES  AFFECTING  THE 
PARTURIENT  CANAL— ( 'ontinued 

Malformations  of  the  Uterus  and  Vagina. 

It  is  only  within  quite  recent  years  that  special  interest  has  attached 
to  the  occurrence  of  pregnancy  in  malformed  uteri.  In  great  part, 
no  doubt,  this  is  because  the  conditions  were  not  appreciated,  and 
because  the  general  and  erroneous  idea  prevailed  that  malformation 
of  the  uterus  precluded  pregnancy.  Many  interesting  cases  are 
now  recorded,  however,  and  every  day  their  number  is  being  added 
to.  As  giving  an  idea  of  the  frequency  of  the  malformation,  I 
may  mention  that  seven  cases  have  been  under  my  personal  super- 
vision— three  cases  of  uterus  didelphys,  one  case  of  uterus  bicornis 
unicollis,  one  case  of  uterus  subseptus,  and  two  cases  of  uterus 
cordiformis. 

Naturally,  it  is  quite  impossible  to  discuss  in  detail  the  various 
malformations  of  the  uterus  and  vagina  which  may  disturb  preg- 
nane}7. I  can  only  give  an  outline  of  the  general  course  these  cases 
run,  and  illustrate  some  of  the  difficulties  which  have  been  recorded 
and  are  likely  to  arise. 

It  will  be  remembered  that  the  tubes,  uterus,  and  vagina  are 
developed  from  the  Miillerian  ducts,  and  that  these  two  ducts  become 
fused,  except  the  uppermost  parts,  which  go  to  form  the  Fallopian 
tubes.  The  varieties  of  malformation  encountered,  therefore,  are  very 
numerous,  and  depend  upon  the  extent  to  which  development  and 
fusion  of  the  two  parts,  which  should  become  blended,  fail.  The 
illustrations  in  Figs.  188  and  184  diagrammatically  represent  the 
various  malformations  which  may  be  encountered. 

As  one  would  expect,  pregnancy  in  a  uterus  unicornis  is  of  extreme 
rarity.  Molderhauer's1  is  the  only  case  I  know  of.  although  I  doubt 
not  others  have  been  recorded. 

As  regards  uterus  bicornis  with  a  rudimentary  horn,  it  is  quite 

1  Arch.  f.  Oyn.,  1'xl.  \ii.,  p.  175. 
294 


MALFORMATIONS  OF  THE  UTERUS  AND  VAGINA     295 

otherwise.  Many  cases  of  this  malformation  have  been  found  where 
the  normal  half  was  pregnant,  and  many  others  where  the  rudi- 
mentary horn  was  gravid.  Very  rarely  indeed  is  there  an  external 
communication  with  the  rudimentary  horn.  Werth,1  in  his  hundred 
collected  cases,  found  a  communication  in  nineteen. 

Interesting  isolated  cases  have  been  recorded  in  this  country  by 
Galabin,2  Targett,3  Cameron,4  etc. 

Fertilization  in  most  cases  takes  place  in  the  following  way :  The 
spermatozoa,  which  pass  up  the  normal  side  and  out  of  the  Fallopian 
tubes,  wander  over  to  the  other  tube,  and  pass  into  it  and  impregnate 
the  ovum. 

A  common  termination  is  rupture  of  the  sac.  This,  according  to 
Kehrer,5  occurred  in  47  per  cent.,  and  according  to  Werth  in  45  per 
cent.  Rarely  does  pregnancy  continue  to  the  later  months ;  but 
Becker6  has  described  such  a  case. 

A  correct  appreciation  of  the  nature  of  the  condition  is  seldom 
come  to  until  the  abdomen  is  opened,  for  the  round  ligament  and 
tube  running  from  the  distal  margin  of  the  sac — the  feature  which 
distinguishes  the  condition  —  are  usually  impossible  to  palpate. 
Targett,  however,  recognized  the  condition  in  his  case  prior  to 
operation. 

The  treatment  is  to  remove  the  sac,  which  as  a  rule  can  be  easily 
carried  out,  as  Galabin,  Targett,  Doran,  and  others,  have  shown ;  but 
I  cannot  linger  over  such  cases,  for  clinically  they  present  features 
more  nearly  resembling  tubal  pregnancy,  and  are  therefore  considered 
in  Chapter  XXXII. 

The  simpler  forms  of  malformation,  such  as  uterus  cordiformis 
and  uterus  subseptus,  are  of  comparatively  little  consequence,  except 
in  so  far  that  they  favour  the  occurrence  of  oblique  presentations, 
as  we  have  already  seen  in  Chapter  VI. 

In  the  malformations  where  there  are  two  distinct  cavities  the 
disturbances  of  pregnancy  are  less  frequent  than  one  might  expect. 
In  the  two  cases  of  uterus  didelphys  which  have  been  under  my  care 
pregnancy  continued  until  term.  Labour  was  but  little  disturbed. 
The  child  was  delivered  with  forceps  when  its  head  had  reached  the 
outlet.  In  both  cases  the  vaginal  septum  was  torn.  The  cases  are 
briefly  described  on  p.  298. 

1  Winckel's    '  Handbuch,'    Bd.    ii.,    Teil  ii.,   1904,  p.  978,  and  Arch.  f.  Gyn. 
vol.  lxxvi.,  p.  48. 

2  Lond.  Obst.  Trans.,  1895,  p.  225.  3  Ibid.,  1900,  p.  276. 

4  Journ.  Obst.  and  Gyn.  Brit.  Empire,  1902,  p.  67. 

5  '  Das  Nebenhorn  der  Doppelten  Uterus,'  Inaug.  Dis.,  1899. 
e  Monat.f.  Gel.  u.  Gyn.,  1905,  vol.  xxii.,  p.  587. 


296  ()I'i;i;\TI\  !•:  MIDWIFERY 


Uterus  Unicornis  (with  rudimentary  Uterus  Unicornis, 

horn). 


Uterus  Subseptus. 


Uterus  Septus. 
Fig.  133.  —  Malformations  of  Uterus. 


MALFORMATIONS  OF  THE  UTEEUS  AND  VAGINA     297 

In  the  English  language  the  most  important  paper  is  by  Giles.1 
Since  Giles'  paper  several  others  have  appeared,  one  of  the  most 
interesting  being  by  Guerin-Valmale.2  This  author  reviews  46  cases 
of  uterus  didelphys.  In  the  104  pregnancies  which  occurred  in  these 
women,  abortion  occurred  in  19,  premature  labour  in  8,  or  a  total 
interruption  of  pregnancy  once  in  4  cases.  Complications,  the  result 
of  auto-intoxication,  seem  more  frequent  than  usual,  for  there  were 
3  cases  of  eclampsia  in  the  104  pregnancies. 


Uterus  Cordiformis. 


¥ 


Uterus  Bicornis  Unicollis.  Uterus  Didelphys. 

Fig.  134. — Malformations  of  Uterus. 

The  labour  is  rarely  complicated.  He  writes :  '  En  somme  la 
delivrance  s'effective  habituellement  avec  la  plus  grande  simplicite, 
sans  accidents  ou  complications  serieuses.' 

Trapet3  has  reviewed  186  collected  cases.  He  found  that  the  com- 
plications and  difficulties  were  not  frequent.  Menstruation  from  the 
non-gravid  half  was  not  common,  although  it  occasionally  occurred 

1  Trans.  Lond.  Obst.  Soc,  1895,  vol.  xxxvii.,  p.  301. 

2  L'Obstetrique,  May,  1904,  p.  209. 

3  Inaug.  Dis.,  Bonn,  1905  ;  ref.  Zent.  f.  Gyn.,  1906,  p.  671. 


298  OPERATIVE  MIDVYIIT.KY 

quite  regularly.  The  decidua  which  formed  in  the  aon-gravid  half 
was  usually  expelled  at  or  ahout  the  time  of  the  delivery  of  the  lotus 
but  occasionally  it  was  expelled  during  pregnancy. 

With  all  varieties  of  double  uterus  difficulties  may  arise.  Some 
of  these  1  will  now  refer  to.  I  have  already  mentioned  that  even 
the  sLijilc  form,  uterus  cordiformis,  may  he  associated  with  mal- 
presentations,  hemorrhage,  retention  of  the  placenta,  i 

An  extraordinary  case  is  that  described  by  Jakesch.1  where  the 
total  head  must  have  been  pushed  through  the  septum.  Halhan 
reports  a  case  where  the  birth  occurred  through  the  cervical  canal  of 
the  non-gravid  side.  But  although  it  must  be  of  extreme  rarity  to 
have  the  uterine  septum  give  way,  it  is  by  no  means  uncommon  for 
the  vaginal  one  to  be  torn.    This  occurred  in  two  cases  under  my  care. 

Case  1.— The  following  notes  regarding  this  case  have  kindly  been 
furnished  to  me  by  Dr.  Baird,  with  whom  I  saw  the  patient  in  consultation  : 
'  In  August,  1904,  about  •">  p.m.,  I  was  called  to  Mrs.  A—  .  a  primipara, 
who  had  nearly  reached  term.  On  vaginal  examination,  I  found  that  tin' 
vagina  was  divided  antero-posteriorly  by  a  septum,  which  extended  from 
immediately  above  the  meatus  urinarius  to  the  centre  of  the  perineum  and 
upwards  to  the  cervix.  On  passing  the  finger  on  each  side,  I  judged  by  the 
feel  that  it  would  be  about  £  inch  in  thickness.  The  septum  was  complete, 
and  I  could  not  get  nry  fingers  to  meet,  not  even  at  the  cervix.  The  two 
passages  were  completely  separate.  The  right  half  seemed  to  become  wider 
and  more  roomy  as  the  finger  passed  upwards,  while  the  left  got  narrower. 
They  both  had  a  vaginal  portion  projecting  into  them.  On  both  sides  the 
cervix  was  obliterated,  and  the  os  about  the  size  of  a  sixpence.  <  >n  seeing 
her  six  hours  later,  the  left  os  had  dilated  to  about  the  size  of  a  crown  piece. 
The  presenting  head  by  this  time  had  detached  the  uppermost  end  of  the 
vaginal  septum.  A  little  later  the  head  was  found  to  have  projected  through 
the  opening  into  the  right  vagina.  The  child  descended  through  the  right 
vagina,  but  was  prevented  from  escaping  by  the  remains  of  the  vaginal 
septum.     At  this  stage  I  asked  Dr.  Munro  Kerr  to  see  the  case  with  me. 

'  After  putting  the  patient  under  chloroform,  Dr.  Kerr  divided  the  septum 
and  extracted  a  living  child  with  forceps.  The  placenta  was  soon  after 
expelled.  A  vaginal  examination  was  made  thereafter,  and  two  distinct 
uterine  bodies  were  felt.  The  remains  of  the  vaginal  septum  were  then 
removed. ' 

Case  2. — J.  McW ,  1-para,  was  admitted  bo  the  Glasgow  Maternity 

Hospital  under  my  care  on  duly  28,  L904,  in  labour.  The  pelvis  was  of  normal 
dimensions.  A  curious  condition  was  discovered,  however— a  double  vagina 
and  uterus  of  the  variety  uterus  duplex  separatus  cum  vagina  separata. 
Labour  was  allowed  to  proceed.  The  foetal  head  in  its  descent  tore  tie-  vaginal 
septum.  No  great  bleeding  took  place,  however,  so  nothing  was  done  until 
the  tearing  process  threatened  the  parts  ahout  the  clitoris,  when  an  incision 
1  Zenhf.  Oyn.,  L897,  729. 


MALFORMATIONS  OF  THE  UTERUS  AND  VAGINA  299* 

with  a  knife  freed  the  last  |  inch  of  the  anterior  attachment  of  the  septum. 
Spontaneous  delivery  took  place  without  any  rupture  of  the  perineum. 

As  I  have  already  said,  the  septum  frequently  tears  during  the  birth, 
but  for  the  torn  septum  to  act  as  a  barrier  to  the  head  or  shoulders, 
as  in  the  above  cases,  is  not  common.     Strauch '  has  recorded  a  case. 

Lukowicz's  case2  is  of  special  interest,  where  the  presenting  breech 
rode  on  the  vaginal  septum.  A  similar  case  has  also  been  recorded 
by  Gardini.3 

A  very  rare  complication  is  for  the  non-gravid  half  to  act  as  an 
obstruction.  Ranken  Lyle4  has  recorded  a  case  where  the  non- 
gravid  half  of  a  uterus  duplex  separatus  cum  vagina  separata,  and 
affected  by  fibroids,  necessitated  Cesarean  section  at  term.  Both 
mother  and  child  were  saved.  V.  Braun  5  described  one  where  Cesarean 
section  was  performed  because  of  a  tumour  impacted  in  the  pelvis, 
which  obstructed  delivery  and  could  not  be  dislodged.  Upon  remov- 
ing the  tumour,  it  was  found  to  be  the  non-gravid  half  of  a  uterus 
bicornis.  Wendling0  has  recorded  a  case  where  a  haematocolpos, 
previously  incised,  formed  again,  and  acted  as  a  barrier  to  delivery f 
until  an  incision  was  again  made  and  the  accumulated  blood  allowed 
to  escape.  Backer's  case7  is  of  interest,  for  although  a  hrematometra 
had  been  present  for  some  years,  the  woman  had  had  no  trouble  at 
four  previous  births.  At  the  fifth  confinement — the  one  described  by 
the  author — laparotomy  was  performed,  on  account  of  the  tumour 
mentioned  obstructing  the  parturient  canal. 

Abortion  is  not  infrequent,  but  rarely  gives  trouble.  Gusserow's8 
experience  is  most  peculiar.  A  three  months  ovum  became  retained 
in  a  closed  vagina  of  a  uterus  didelphys,  and  could  only  be  removed 
by  dividing  the  septum.  Plural  pregnancy  has  been  observed 
frequently.     Nowikow9  has  described  three  most  interesting  cases : 

(1)  A  multipara  delivered  of  a  premature  child  was  discovered 
to  have  a  swelling  towards  the  left  of  the  abdomen,  which  was 
diagnosed  as  a  pregnancy  of  seven  months  in  the  one  half  of  a 
double  uterus.     Two  months  after  a  full-time  living  child  was  born. 

(2)  A  multipara  had  a  full-time  child.  Soon  after  its  birth  a  three 
months  ovum  was  discharged.  (3)  A  multipara  was  delivered  of  two 
full-time  children  at  an  interval  of  forty-seven  days.     Paulin10  records 

1  Zent.  f.  Gyn.,  1887,  No.  43,  p.  684.  2  Ibid,,  1886,  No.  85,  p.  572. 

3  Anal.  cVObst.  et  Gyn.,  September,  1899. 

4  Journ.  Obst.  and  Gyn.  Brit,  Empire,  December,  1904,  p.  438. 

5  Zent,  f.  Gyn.,  1895,  p.  579.  6  Wien.  Klin.  Woch.,  1896,  No.  2. 
■   Zent.f.  Gyn.,  1896,  p.  883.                     s  Charitr  Annal,  1900,  p.  618. 

9  Eef.  Zent.f.  Gtjn.,  1902,  p.  861. 
111  lief.  Epit.,  Brit.  Med,  Journ.,  1905,  No.  SO,  vol.  i. 
\ 


800  OPERATIVE   MIDW1I  in 

a  twin  labour,  bhe  children  being  born  at  seventeen  days' interval. 
Daring  the  interval  there  was  no  lochia,  nor  any  active  secretion  of 
milk.  Both  children  were  alive,  and  were  suckled  by  the  mother. 
A   distinct  Beptnm   divided  the  uterus  into  two  compartments,  but 

there  was  no  .-ulcus  at  the  fundus. 

Trapet1  has  added  to  the  cases  collected  by  <iiles  and  Guerin- 
Valmale,  and  has  collected  from  the  literature  on  the  subject  sixteen 
cases  of  plural  pregnancy.  He  describes  a  new  case,  in  which  the 
children  were  born  at  an  interval  of  fourteen  days. 

Another  complication,  but  of  a  much  more  serious  nature,  is 
rupture  of  the  uterus.  One  of  the  most  striking  examples  of  this  is 
a  case  recorded  by  Donald  and  Walls.-  The  case  (Fig.  185)  was  one 
of  uterus  bicornis  unicollis  in  which  two  ruptures  occurred,  one  in 
the  ridge  between  the  uterine  bodies  and  the  other  in  the  right 
anterior  wall.  The  labour,  which  was  the  sixth,  was  very  protracted. 
The  fifth  labour  was  specially  interesting,  for  the  right  horn,  which 
contained  the  placenta,  was  incarcerated  in  the  pelvis,  and  obstructed 
the  delivery.  Winter's  case3  is  also  of  peculiar  interest,  and  quite 
unique  as  far  as  I  know — complete  inversion  and  rupture  of  the  left 
half  of  a  double  uterus. 

It  is  not  to  be  wondered  at  that  rupture  should  occur,  for  the 
delivery  is  sometimes  difficult,  and  the  double  uterus,  especially  the 
variety  with  one  cervix,  is  much  weaker  in  its  wall  than  a  normal 
uterus,  liupture  of  the  '  infantile  uterus '  is  referred  to  in  connexion 
with  rupture  of  the  uterus  (Chapter  XXXY.i. 

It  is  self-evident  that  the  diagnosis  of  double  uterus  must  fre- 
quently be  very  difficult,  and  that  mistakes  are  sometimes  un- 
avoidable. When  two  vagina  or  two  cervices  are  discovered,  the 
nature  of  the  condition  is  at  once  apparent.  It  often  happens, 
however,  that  only  one  vagina  is  recognized — the  one  which  has 
been  used  for  intercourse  ;  also  in  not  a  few  cases  the  abnormality  is 
a  uterus  bicornis  unicollis.  One  of  the  most  common  mistakes  is  to 
consider  the  gravid  half  an  ectopic  sac,  and  on  several  occasions  the 
abdomen  has  been  opened  under  that  idea. 

Four  years  ago  I  had  an  interesting  case  of  uterus  bicornis 
unicollis,  which  was  sent  to  me  by  Dr.  Campbell,  Partick,  with  a 
provisional  diagnosis  of  extra-uterine  pregnancy.  The  woman  was 
a  multipara,  aged  thirty.  When  I  saw  her,  an  abdominal  tumour, 
consisting  of  two  unequal  parts,  occupied  the  lower  part  of  the 
abdomen.  The  woman  gave  the  history  of  having  missed  two 
menstrual  periods,  and  having  had   for   some  six  weeks  much    ab- 

1  Inaug.  Dis.,  Bonn,  1905.  -  Practitioner,  June,  1903. 

3  Zenf.f.  Gyn.,  1887,  p   81  I. 


3 
Ot- 

a 


ft 
I 


302  01  ERATIVE  MIDWIFERY 

dominal  pain  and  irregular  vaginal  hemorrhages.  Extra-uterine 
pregnancy  1  dismissed,  however,  after  a  careful  bimanual  examina- 
tion, and  came  to  the  conclusion  that  I  bad  probably  to  do  with  an 
ahortion  in  either  a  hicornate  or  myomatous  uterus.  The  pas.-. 
of  the  uterine  sound  into  two  distinct  cavities  showed  it  was  the 
former.  Piith1  descrihes  a  case  where  the  ahdomen  was  opened  for 
a  supposed  extra-uterine  pregnancy,  and  a  gravid  uterus  hicornis 
anicollis  was  discovered. 

Theoretically,  the  position  of  tubes,  ovaries,  and  round  ligaments 
Bhould  decide  the  diagnosis,  and  undoubtedly  it  often  does  ;  hut  one 
cannot  always  make  certain  of  the  exact  nature  of  the  structures  felt 
between  the  two  examining  hands.  Still,  as  in  all  other  pelvic 
conditions,  care,  time,  and  reflection  will  usually  result  in  a  correct 
diagnosis. 

As  regards  treatment,  it  is  equally  difficult  to  generalize.  We  have 
already  seen  that  in  cases  of  pregnancy  in  a  rudimentary  horn  tin- 
latter  may  be  removed  and  the  other  half  of  the  uterus  left  behind, 
.and  Doran  is  even  able  to  record  a  case  where  pregnancy  followed. 
But  with  any  other  condition  I  question  if  any  operative  treatment  is 
likely  to  improve  matters. 

I  think  it  wise  to  leave  the  cases  of  double  uterus  alone,  for  in 
most  cases  labour  is  not  greatly  disturbed.  Even  the  serious  cases 
I  have  described  have  many  of  them  been  made  more  so  by  the 
methods  of  treatment  adopted.  As  a  matter  of  fact,  the  uterus 
cordiformis — the  simplest  of  all  malformations — is  the  one  which 
most  frequently  gives  trouble,  for  it  is  associated  so  generally  with  a 
transverse  presentation. 

1  Zent.  f.  Gyn.,  1905,  No.  27,  p.  874. 


CHAPTER  XXI 

PREPARATIONS  FOR  OPERATION— PREPARATION 
OF  OPERATING-ROOM— INSTRUMENTS  AND  APPLIANCES 
OPERATOR'S  HANDS-PATIENT-ANjESTHESIA 

The  ideal  room  for  an  accouchement  is  naturally  the  labour-room  of 
a  modern  maternity  hospital,  whose  floors  and  walls  can  be  washed 
down  from  time  to  time,  and  whose  furniture  consists  of  a  few  wash- 
hand  basins  and  a  labour-couch.  But  midwifery  work  in  general 
cannot  be  carried  out  in  such  a  room,  seeing  that  confinements  are 
conducted  in  private  dwellings,  where  there  is  little  choice  of  the 
apartment. 

Fortunately,  the  dangers  of  infection  from  the  atmosphere  of  a 
room  are  comparatively  slight.  The  only  exception  is  in  the  case 
of  a  room  into  which  sewer-gas  escapes  from  a  set-in  basin  badly 
trapped  or  from  a  water-closet  ventilating  into  the  room.  Such  errors 
in  sanitation,  however,  are  now  fortunately  comparative^  rare,  and 
cases  of  poisoning  such  as  Playfair1  and  others  have  described  are 
almost  unknown.  One  may  therefore  dismiss  the  question  of  the 
room. 

More  important  is  the  bed  upon  which  the  patient  lies.  This 
should  always  be  well  protected  by  mackintoshes  covered  by  clean 
sheets.  These  conveniences,  however,  in  the  houses  of  the  poor  are 
often  not  available,  so  that  it  was  my  custom  in  doing  district  work  to 
carry  with  me  a  piece  of  thin  jaconet. 

As  regards  the  extremely  poor  and  destitute,  it  is  apparent  that 
they  cannot  be  satisfactorily  attended  in  their  own  homes ;  conse- 
quently, they  should,  when  at  all  possible,  be  transferred  to  an 
institution  suitable  for  such  cases. 

Even  amongst  those  in  comfortable  circumstances,  there  is  a 
tendency  to  employ  and  use  up  at  a  confinement  any  old  linen  and 
clothing  that  is  available.  This,  of  course,  is  quite  permissible  if 
such  articles  are  thoroughly  cleansed  beforehand,  but,  unfortunately, 

1  '  The  Science  and  Practice  of  Midwifery,'  9th  edition,  vol.  ii.,  p.  365. 

303 


804  OPEBATIVE   MIDWIFERY 

that  is  hardly  ever  done.  I  feel  convinced,  however,  that  if  nurses 
and  practitioners  would  impress  upon  patients  the  importance  of 
having  clean  garments  for  the  confinement,  the  majority  of  patients 
would  respond  to  such  a  suggestion,  and  have  everything  ready 
ili.it  was  required.  It  entails  little,  if  any.  expenditure  of  money. 
and  should  he  as  easy  for  those  with  only  very  limited  means  as  for 
those  in  comfortahle  circumstances. 

Instruments. 

All  instruments  and  appliances  must  be  sterile.  In  a  hospital 
that,  of  course,  is  easily  accomplished,  hut  even  in  private  practice 
the  sterilization  of  them  is  not  difficult. 

Metal  Instruments  are  sterilized  by  boiling.  Prior  to  doing  this 
they  should,  if  not  previously  washed,  be  scrubbed  with  soap  and 
water.  This  scrubbing  with  soap  and  water  is  best  done  immediately 
after  the  instrument  is  soiled,  for  dry  blood-clot  is  difficult  to  remove. 
The  sterilizer  generally  seen  in  hospital  is  that  of  Schimmelbusch, 
but  an  ordinary  fish-kettle  does  quite  as  well.  Very  commonly  some 
sodium  carbonate  is  put  into  the  water ;  it  has  the  effect  of  raising 
the  temperature  and  lessening  the  injury  to  the  plating  on  the 
instruments.  When  removed  from  the  boiling  water,  they  should  be 
placed  in  trays  or  some  convenient  dish,  and  covered  over  with 
saline  solution.  If  the  operation  is  in  a  hospital  or  nursing  home 
it  is  unnecessary  to  immerse  them  in  strong  antiseptic  solutions, 
as  such  solutions  irritate  any  mucous  membrane  or  raw  surface  with 
which  they  are  brought  into  contact.  The  only  advantage  of  a  weak 
antiseptic  solution  such  as  carbolic  1  in  60  is  that  it  does  not  rust  the 
instruments.  When  the  instruments  have  to  be  sterilized  at  home 
they  should  be  wrapped  up  in  a  sterilized  towel  after  boiling.  Before 
use  I  always  put  them  in  a  solution  of  carbolic  (1  in  30).  I  never 
attempt  aseptic  midwifery  in  private  practice.  During  the  operation 
soiled  instruments  should  be  immersed  occasionally  in  an  antiseptic 
solution. 

Knives  should  be  sterilized  by  boiling,  the  blades  being  protected 
by  gauze,  for  otherwise  the  edges  are  blunted.  A  common  practice 
for  sterilizing  knives  is  immersing  them  in  1  in  70  alcohol,  but  this  is 
not  quite  sufficient  unless  they  are  immersed  in  it  for  some  time. 

Trays  and  Dishes  containing  the  instruments  should  be  sterilized. 
In  the  Maternity  Hospital  we  do  this  by  immersing  them  in  a  strong 
solution  of  1  in  500  bichloride  of  mercury ;  but  a  large  copper  tank, 
in  which  they  can  be  boiled,  is  better.  In  private  houses  all  basins, 
ewers,  or  other  dishes  should  be  well  wrashed  with  soap  and  water 
and  carbolic  solution  (1  in  20). 


INSTRUMENTS  805 

Rubber  Instruments  without  joints,  such  as  the  douche-tubes, 
gloves,  Barnes'  bags,  can  be  quite  "satisfactorily  sterilized  by  boiling. 
Champetier  de  liibes'  bag,  however,  I  am  in  the  habit  of  sterilizing  by 
immersion  in  perchloride  of  mercury,  1  in  1,000,  for  twenty-four 
hours.  (It  is  impossible  to  sterilize  the  bag  by  boiling,  as  it  is  perma- 
nently injured.)  I  always  keep  one  ready  for  use  in  a  sterilized  towel. 
Bougies  for  induction  of  labour  are  best  sterilized  by  soaking  in  the 
same  solution,  although,  if  required  in  a  hurry,  they  may  be  boiled 
with  safety  ;  the  only  objection  to  the  boiling  is  that  it  roughens  the 
smooth  surface  of  the  instrument. 

Swabs,  Sponges,  Dressings. 

The  materials  used  for  swabbing  in  the  Glasgow  Maternity  Hospital 
are  cotton-wool  and  gauze  sponges  in  the  indoor  department,  and 
carbolized  tow  in  the  outdoor.  We  never  use  ordinary  marine  sponges 
for  abdominal  work,  although  there  is  a  good  deal  to  be  said  in  their 
favour,  as  they  are  so  soft  and  absorbent.  They  are  difficult  to 
sterilize,  however.  Gauze  and  cotton-wool  swabs,  along  with  all 
dressings,  are  sterilized  in  the  steam  sterilizer. 

In  private  obstetric  practice  gamgee  is  the  material  most  employed 
for  sponging,  and  it  is  generally  used  as  it  comes  from  the  maker. 
Used  in  that  way  gamgee  is  not  without  danger,  as  it  is  not  sterile. 
A.  simple  device  is  to  boil  it,  and  then  run  off  the  water  and  let  it  dry 
in  the  kettle,  or  wring  it  out  of  biniodide  of  mercury,  1  in  1,000,  and 
use  it  wet.  Undoubtedly  a  supply  of  sterilized  gauze  should  be  one  of 
the  requisites  for  the  accouchement. 

For  abdominal  operations  the  gauze  swabs  are  arranged  in  bundles 
of  ten.  I  find  that  usually  about  fifty  are  required  for  a  Cesarean 
section,  and  about  ten  or  fifteen  less  for  any  ordinary  abdominal 
section.  They  maybe  used  dry  or  soaked  in  a  normal  saline  solution. 
It  is  a  good  precaution  to  have  tapes  attached  to  all  swabs  that  are 
pushed  into  the  abdominal  cavity,  and  to  fasten  a  pair  of  forceps  to 
the  ends  of  each  tape.  The  swabs  must,  of  course,  be  carefully  counted 
before  the  abdomen  is  closed. 

The  interest  in  dressings  is  not  so  great  now  as  formerly.  In 
hospital  and  private  nursing  homes  sterilized  gauze  is  the  only  dress- 
ing I  employ,  unless  the  wound  is  being  drained  or  is  septic,  when  I 
employ  an  antiseptic  dressing.  For  packing  the  uterus  or  any  cavity 
I  usually  employ  iodoform  gauze  (5  to  7  per  cent.).  In  domestic 
practice,  where  asepsis  is  almost  impossible,  one  of  the  antiseptic 
dressings,  such  as  the  double  cyanide  gauze,  is  better  for  packing- 
cavities,  as  iodoform  gauze  is  not  a  good  drain. 

20 


306  OPERATIVE  Ml  I  >WI1T.I;Y 

Ligatures  and  Sutures. 

Silk.— Silk  should  he  loosely  wound  on  glass  spools  or  plates; 
there  Bhoald  oot  be  too  much  on  «>ne  spool.  It  is  readily  sterilized  l>y 
boiling  in  water  for  twenty  to  thirty  minutes.  It  may  then  he 
preserved  in  a  solution  of  carbolic,  1  in  80,  or,  hetter,  bin  iodide  of 
mercury  and  70  per  cent,  alcohol  1  in  1,000.  Before  use  it  may  be 
washed,  hut  it  is  more  conveniently  manipulated  when  taken  directly 
from  the  alcohol  solution.  It  is  advisahle  when  using  silk  to  employ 
the  finest  variety  that  will  serve  the  purpose.  Personally,  I  try  to 
use  silk  as  little  as  possible  ;  indeed,  for  the  last  year  or  more  I  have 
used  nothing  hut  catgut. 

Several  operators  speak  highly  of  Pagenstecher's  celluloid  thread. 
Moynihan,  for  example,  prefers  it  to  silk.  We  used  it  for  a  short 
time  in  the  Glasgow  Maternity  Hospital,  but  did  not  find  it  possessed 
any  advantages  over  silk.  It  Is  sterilized  by  boiling  in  the  same  way 
as  silk.  In  an  emergency,  and  when  neither  of  these  materials 
mentioned  is  available,  sterilized  linen  thread  is  quite  a  useful 
material. 

Silk-worm  Gut. — Silk-worm  gut  is  readihy  sterilized  by  boiling 
for  twenty  to  thirty  minutes.  It  maybe  kept  in  either  the  carbolic 
biniodide  solutions  already  mentioned.  But  it  must  be  washed  well 
in  water,  otherwise  it  breaks  very  readily.  It  is  a  most  useful  suture, 
and  I  employ  it  always  for  the  abdominal  wound  and  the  perineum  in 
the  manner  I  will  describe  when  considering  these  wounds. 

Catg^ut. — The  sterilization  of  catgut  is  too  big  a  subject  to 
discuss  in  detail.  Much  has  been  written  regarding  it,  and  there  are 
a  great  number  of  methods  recommended.  At  the  present  time  the 
one  most  favoured  is  by  means  of  iodine.  Claudius  some  three  or 
four  years  ago  recommended  this  method.  The  ordinary  coninierei.il 
catgut  is  steeped  for  eight  days  in  a  solution  of  iodine,  1  part  ; 
potassium  iodide.  1  part ;  and  water,  100  parts.  Before  use,. 
Claudius  recommends  its  being  thoroughly  well  washed  to  remove 
the  excess  of  iodine.  Several  operators  have  recently  advocated  the 
addition  of  alcohol.  Scott  Piiddell1  contributed  an  interesting  article 
on  the  subject,  and  reported  certain  investigations  carried  out  by 
McDonald  where  a  solution  of  tincture  of  iodine  1  part  and  proof 
spirit  15  parts  was  employed.  It  appears  that  this  solution  is  an 
excellent  germicide,  and  that  anthrax  spores  and  ]><i<illits  mesentericus 
were  killed  in  three  and  six  days  respectively. 

Iodized  catgut  appears  not  to  be  absorbed  too  quickly,  standing 
midwaj'  between  the  ordinary  catgut  sterilized   by  the  older  methods 

1  Brit.  Med.  Journ.,  April  6,  1907. 


PREPARATION  OF  OPERATOR  AND  ASSISTANTS      307 

and  chromicized  catgut.  At  the  present  moment  the  most  modern 
operators  speak  very  highly  of  iodized  catgut,  but  the  last  word 
regarding  the  sterilization  of  this  most  perfect  ligature  has  not  yet 
been  spoken. 

For  some  years  in  the  Glasgow  Maternity  Hospital  the  catgut 
was  prepared  by  boiling  in  alcohol  under  pressure  in  a  Jellett  or 
Robson  metal  vessel.  I  was  not  quite  satisfied,  however,  with  the 
catgut  prepared  in  that  way.  A  very  convenient  preparation  is 
Van  Horn's,  made  up  in  sealed  glass  tubes.  The  smaller  sizes  up  to 
No.  2  I  have  found  very  satisfactory,  and  although  one  is  prejudiced 
against  employing  catgut  not  made  under  one's  own  direction,  I  feel 
satisfied  that  the  smaller  sizes  of  Van  Horn  catgut  can  be  used  with 
perfect  safety.  Now  that  there  is  such  a  simple  method  as  the  iodine 
one  for  sterilizing  catgut,  there  is  no  reason  why  one  should  not 
sterilize  the  gut  for  oneself. 

Preparation  of  the  Operator  and  Assistants. 

In  ordinary  domestic  obstetric  practice,  the  most  the  accoucheur 
can  do  is  to  clothe  himself  in  a  sterile  gown,  and  this  all  of  us  are 
now  in  the  habit  of  doing.  For  abdominal  work  in  hospital  and  private 
nursing  homes  many  operators  go  farther,  and  wear  caps  and  masks, 
and  quite  rightly,  for  the  head  of  the  operator  and  his  assistant 
frequently  come  in  contact,  and  both  breathe  over  the  wound  large 
quantities  of  organisms. 

In  preparing  for  an  abdominal  operation  or  for  an  ordinary 
accouchement,  the  preparation  of  the  hands  of  the  operator  and  his 
assistants  is  the  most  important  part  of  their  toilet.  That  being 
so,  it  is  not  to  be  wondered  at  that  it  has  been  so  much  discussed 
and  written  about.  It  would  be  quite  impossible  to  consider  this 
subject  in  detail.  I  would  refer  those  who  are  specially  interested 
in  it  to  two  monographs — one  a  translation  by  C.  Heron  "Watson 
of  Haegler's  most  important  work,  '  Cleansing,  Disinfection,  and 
Protection  of  the  Hands,'  the  other  a  small  but  very  excellent  book 
by  C.  Leedham  Green,  '  The  Sterilization  of  the  Hands.' 

Although  it  is  somewhat  disappointing  to  think  that  it  is  impossible 
to  sterilize  the  hands  completely  by  any  known  device,  it  is  a  matter 
of  great  satisfaction  to  learn  that  the  simplest  of  all  methods  of 
cleansing  them  is  the  best.  Haegler  wTrites  (p.  35)  :  '  It  follows, 
therefore,  from  these  examinations,  that  the  principal  provisions  for  a 
successful  and  mechanical  cleansing  are  hot  water,  soap,  and  a 
scrubbing  instrument  to  be  used  during  the  washing,  and  a  rough 
towel  with  which  to  rub  the  hands.'     As  regards  the  hot  water,  the 


308  OPERATIVE  MIDWIFER! 

important  matter  is  that  the  water  should  he  running  or  frequently 
changed,  as  otherwise  one  rubs  into  the  Bkin  the  organisms  which 
have  been  already  removed. 

Different  Boaps  have  been  recommended  from  time  to  time,  such 
as  alkaline  Boap,  green  soap,  marble  dust  soup,  li  does  oot, however, 
appear  to  be  of  very  much  importance  which  of  them  is  used,  nor 
does  it  seem  of  any  advantage  to  combine  the  antiseptic  with   the 

soap. 

Haegler  is  a  strong  advocate  of  the  brush,  and  found  none  of  the 
substitutes  were  so  good;  the  same  brush,  however,  should  not  be 
used  all  the  time.  It  is  advisable  to  employ  two  nail-hrushes  at 
least,  one  for  the  first  part  of  the  scrubbing,  and  the  other  for  the 
second  part.  In  addition  to  the  soap  and  nail-brush,  fine  white 
sterile  sea-sand  is,  according  to  Leedham  Green,  an  advantage,  and 
can,  of  course,  be  used  in  hospitals  or  private  nursing  homes. 

The  cleansing  of  the  nails  is  of  great  importance.  I  have  never 
cared  for  the  sharp  metal  nail-cleaner,  but  prefer  a  bone  one  and 
gauze.  Haegler  for  the  nails  found  the  best  results  obtained  with 
silk  threads.  He  states  (p.  65) :  '  The  wiping  out  of  the  space  under 
the  nail  with  a  rough  but  pliant  medium  is  far  more  efficacious  than 
is  the  work  of  the  nail-cleaner,  and  the  efficacy  of  the  thread  is 
increased  by  the  progressive  maceration  of  the  epidermis/  Silk 
threads,  however,  are  very  liable  to  cut  the  skin,  and  they  are  not 
easily  used. 

Having  completed  the  scrubbing  of  the  hands,  which  should  occupy 
about  seven  to  ten  minutes,  the  next  consideration  is  the  antiseptic 
that  should  be  subsequently  used.  There  are  three  generally 
employed  in  practice :  carbolic  acid,  mercury  (either  the  biniodide  or 
bichloride),  and  alcohol. 

In  the  early  days  of  antiseptic  surgery  great  importance  was 
attached  to  the  washing  of  the  hands  in  antiseptic  solutions,  and 
many  varieties  of  antiseptics  were  suggested  and  tried.  The  only 
two,  however,  which  have  stood  the  test  of  time  are  carbolic  acid  and 
mercuric  chloride  or  iodide.  The  former  was  employed  very  ex- 
tensively by  Lister,  and  is  still  favoured  b}^  some  surgeons,  including 
Sir  Hector  C.  Cameron  and  Sir  William  Macewen  of  Glasgow 
Universit}\  To  the  large  majority  of  modern  surgeons,  however, 
carbolic  acid  is  anathema.  Without  doubt,  as  Lister  pointed  out  long 
ago,  carbolic  acid  has  a  marvellous  power  of  penetrating  and  com- 
bining with  fats.  For  everyday  practice,  therefore,  the  thorough 
cleansing  of  the  hands  with  soap  and  water  for  seven  minutes,  and  the 
subsequent  steeping  of  them  in  carbolic  acid,  1  in  20,  for  two  minutes 
is  quite  sufficient. 


PREPARATION  OF  OPERATOR  AND  ASSISTANTS      809 

In  the  face,  however,  of  recent  investigations  on  the  sterilization 
of  the  hands  and  skin  generally,  one  is  forced  to  admit  that  a  more 
thorough  cleansing  of  the  skin  is  obtained  by  the  use  of  alcohol  and 
mercuric  iodide.  Mercuric  chloride  and  iodide,  the  great  rivals  of 
carbolic  acid,  have  again  come  to  be  freely  employed  since  the  value 
of  alcohol  as  an  antiseptic  has  been  demonstrated. 

Much  has  been  written  and  varied  have  been  the  views  expressed 
regarding  the  value  of  alcohol  as  an  antiseptic.  Without  doubt,  how- 
ever, it  is  a  most  valuable  addition  to  the  means  we  previously  had 
for  cleansing  the  hands.  It  removes  fats,  and  so  permits  the  mercuric 
solution  penetrating  the  tissues.  It  also  dehydrates,  and  thus  hardens 
the  epithelium  and  acts  as  a  germicidal  agent.  It  appears  to  be  of 
most  value  at  70  per  cent.,  the  stronger  solutions  being  distinctly 
feebler  in  their  action. 

As  regards  the  mercuric  salt  employed,  the  iodide  possesses  certain 
advantages  over  the  perchloride ;  it  is  stronger,  penetrates  better  into 
the  tissues,  and  irritates  the  skin  less.  It  may  be  combined  with  the 
methylated  spirit,  or  used  in  an  aqueous  solution  after  the  washing 
with  alcohol.  Haegler  believes  the  latter  is  better,  but  Leedham 
Green  has  found  the  alcoholic  solution  of  the  mercuric  iodide  more 
efficacious. 

As  far  as  I  can  judge  from  the  writings  of  those  most  competent 
to  express  an  opinion  about  the  matter,  alcohol  and  mercuric  iodide, 
1  in  1,000,  is  better  than  carbolic  acid,  1  in  20  ;  but  the  aqueous 
solution  of  the  mercuric  salt  is  not  so  good  as  the  carbolic. 

In  domestic  practice,  if  methylated  spirit  can  be  obtained,  and  the 
operator  is  prepared  to  take  the  time  that  the  alcohol  and  mercury 
process  involves,  that  is  the  best  method.  If,  however,  methylated 
spirit  cannot  be  obtained,  carbolic  acid,  1  in  20,  is  better  than  mercuric 
iodide  alone,  and,  consequently,  is  probably  the  best  method  of 
cleansing  the  hands  in  ordinary  general  practice. 

In  the  Glasgow  Maternity  Hospital  we  have  employed  the  follow- 
ing method  for  the  last  six  or  seven  years — it  is  Furbringer's  method 
slightly  modified :  (1)  The  hands  are  scrubbed  with  nail-brushes, 
soap,  and  hot  running  water  for  ten  minutes,  the  nails  being  cleaned 
with  a  nail-cleaner  and  gauze.  (2)  After  being  rubbed  over  with 
turpentine,  they  are  washed  in  methylated  spirit.  (3)  They  are  then 
soaked  and  scrubbed  with  mercuric  chloride  or  biniodide  for  three  or 
four  minutes.  (4)  Lastly,  they  are  rinsed  with  a  weak  lysol  solution, 
which  removes  the  mercuric  solution  on  the  surface  and  acts  as  a 
lubricant. 

Without  doubt  our  hands  occasionally  suffer  from  this  treatment, 
but  to  a  less  extent  since  we  abandoned  using  a  strong  lysol  solution. 


310  OPERATIVE   MlhWI  1TJ;Y 

The  hands  stand  the  various  antiseptics  very  differently,  hut  if  they 
are  well  washed  and  rubbed  over  with  glycerine  and  water,  and  dried 
after  any  manipulations  Or  examinations,  they  remain  fairly  smooth. 

My  own  hands  hear  the  treatment  referred  to  much  hetter  than  if  I 
use  carbolic  and  strong  lysol  solution,  but  others  find  the  mercuric 
salts  very  trying.     The  bin  iodide  is,  however,  very  much  less  severe 
on  the  hands  than  the  perchloride ;  I  cannot  understand,  theret 
why  it  is  not  more  generally  used. 

"Without  doubt  this  exhaustive  cleansing  of  the  hands  is 
irksome,  and  occupies  a  considerable  amount  of  time;  therefore  the 
busy  practitioner  is  apt  to  scamp  it.  I  cannot,  however,  see  how  it 
is  to  be  avoided  if  the  mortality  and  morbidity  in  child-bed  is  to  be 
lessened.  As  you  are  aware,  in  domestic  practice  it  is  as  high  to-day 
as  ever  it  was,  while  in  maternity  hospitals  it  has  been  reduced  to 
an  extraordinary  extent.  Indeed,  in  cases  not  interfered  with  before 
admission  to  hospital  septic  manifestations  are  almost  unknown. 

Rubber  Gloves. — In  recent  years  a  further  means  of  protection 
against  conveying  infection  is  the  employment  of  rubber  gloves.  The 
advantages  of  impermeable  gloves  everyone  admits.  The  silk  variety 
are  of  no  value  unless  used  over  the  rubber.  The  objection  urged 
against  them  that  the  tactile  sense  is  impaired  is  not  the  experience 
of  those  who  employ  them.  For  the  last  five  years  I  have  used  them 
in  every  abdominal  operation,  and  have  found  no  inconvenience  from 
them,  provided  they  were  well  fitting.  I  cannot,  however,  speak  so 
emphatically  in  their  favour  in  connexion  with  my  obstetric  work, 
for  although  in  ordinary  vaginal  examinations  and  deliveries  with 
forceps  I  have  had  no  inconvenience  from  them,  I  have  sometimes 
found  that  I  could  not  obtain  a  satisfactory  hold  of  the  child's  leg  in 
version,  for  example,  and  that  I  could  not  grasp  hold  of  portions  of 
adherent  membrane  when  these  were  retained  in  the  uterus.  Indeed, 
in  these  latter  operations  I  have  sometimes  required  to  remove  the 
gloves  before  I  could  carry  out  the  manipulations  necessary. 

The  general  practitioner  might  often,  I  think,  with  advantage 
employ  gloves,  and  I  am  glad  to  find  that  some  of  my  friends  have 
commenced  doing  this.  I  would  recommend  their  use  in  two  ways, 
either  employing  them  for  all  septic  work,  and  so  preventing  the 
hands  from  being  contaminated,  or  using  them  in  all  obstetric  work. 
They  should  always  be  employed  when  giving  vaginal  or  intra-uterine 
douches  in  septic  cases. 

It  must  be  remembered  that  the  employment  of  gloves  in  no  way 
lessens  the  necessity  for  thorough  cleansing  of  the  hands  beforehand. 
The  same  precautions  must  be  taken  with  the  hands  whether  gloves 
are  used  or  not ;  gloves  are  only  an  additional  protection  against 
conveying  infection. 


PREPARATION  OF  OPERATOR  AND  ASSISTANTS      811 

The  difficulty  in  putting  on  rubber  gloves  may  be  overcome  in  two 
ways  :  the  gloves  may  be  filled  with  sterile  water,  when  the  hand  can 
be  very  easily  introduced  into  them  and  the  water  squeezed  out ;  but 
it  is  better  that  they  should  be  applied  dry,  so  that  now  in  hospital 
before  an  abdominal  section  I  thoroughly  dry  my  hands  with  a  rough 
towel,  then  rub  them  over  with  sterile  chalk,  when  the  gloves  can  be 
easily  pulled  on.  As  I  have  already  stated,  they  are  easily  sterilized 
by  boiling,  and  if  one  uses  them  only  in  operating  upon  septic  cases 
and  douching  out  a  septic  uterus,  etc.,  the  thicker  varieties  are  quite 
satisfactory,  and  stand  much  longer  than  the  thinner. 

Assistants.— The  fewer  hands  coming  directly  in  contact  with 
the  parturient  canal  or  the  abdominal  wound  the  better,  for  every 
additional  one  increases  the  risk  of  infection  being  introduced.  In 
obstetric  practice  the  accoucheur  is  really  the  only  one  whose  hands 
enter  the  parturient  canal,  the  most  that  is  required  of  the  assistant 
being  the  holding  of  an  instrument,  such  as  the  blade  of  the  forceps 
or  a  vulsellum.  In  abdominal  work,  however,  it  is  necessary  to  have 
one  assistant  directly  helping  the  operator  and  two  nurses,  one  looking 
after  the  swabs,  the  other  after  the  instruments,  ligatures,  etc.  The 
assistant  and  nurses  should  prepare  themselves  for  the  operation 
as  carefully  as  the  operator,  and  should  wear  gloves.  It  is  a  great 
comfort  to  an  operator  to  feel  that  the  hands  of  those  assisting  cannot 
introduce  any  infection.  I  am  sure  that  the  nurse  threading  ligatures 
and  pulling  the  catgut  or  silk  through  her  fingers,  and  the  other  nurse 
wringing  the  sponges  or  swabs,  are  decided  dangers  if  their  hands  are 
not  gloved.  One  may,  of  course,  dispense  with  nurses  altogether,  in 
which  case  the  swabs  are  taken  directly  from  the  sterilizing  drum  by 
the  assistant,  and  the  needles  are  threaded  by  the  operator.  I  have 
found  this  inconvenient,  however,  and  so  I  prefer  employing  two 
nurses  as  I  have  described. 

Preparation  of  the  Patient. 

Vulva  and  Vagina.  —  We  have  seen  how  the  hands  are  to  be 
cleansed,  so  that  all  operations  and  manipulations  may  be  performed 
with  as  little  risk  as  possible  of  the  patient  being  infected  by  the 
operator's  hands.  But,  even  when  such  cleansing  of  the  hands  is 
carried  out,  there  remains  another  weak  spot  in  the  precautionary 
measures  taken  against  infection — namely,  the  toilet  of  the  vulva. 
No  modern  surgeon  would  dream  of  performing  any  operation  without 
first  thoroughly  cleansing  the  field  of  operation,  yet  the  accoucheur  is 
in  the  habit  of  performing  all  manner  of  manipulations  in  the  vagina 
with  only  a  very  cursory  and  superficial  cleansing  of  the  vulva,  an 
area  which  is  the  most  septic  in  the  whole  body.     Without  doubt  a 


312  OPERATIVE   MIDWIFES! 

large  proportion  of  the  septic  complications  following  parturition  is 
due  to  tin;  organisms  from  this  area  being  pushed  in  by  the  operator's 
bands  or  instruments. 

It  will  be  admitted  by  every  one  bhat  the  most  thorough  cleansing 
of  the  vulva  and  surrounding  part.'-  is  obtained  when  the  pubes  is 

sliavcil  and  the  parts  arc  washed  with  soap  ami  water  and  carbolic  or 
alcohol  and  mercuric  solution. 

At  the  present  time  there  is  a  great  objection  to  such  an  extensive 
toilet,  hut  I  feel  convinced  that  the  time  will  come  when  it  will  he  a 
matter  of  routine  practice.  If  the  importance  of  such  a  cleansing  were 
explained  to  patients,  I  feel  sure  they  would  make  little  objection  to  it. 
for,  after  all,  the  discomfort  of  the  proceeding  would  occur  only  two 
or  three  times,  at  most,  in  a  woman's  lifetime.  But  I  need  not 
enlarge  or  pursue  this  suhject  farther — it  is  not  at  present  within  the 
range  of  practical  obstetrics.  The  most  that  can  be  done  in  domestic 
practice  is  to  cut  the  hair  short,  carefully  wash  the  parts  with  s<>ap 
and  water,  taking  care  that  all  the  crevices  about  the  labia  and 
clitoris  are  thoroughly  cleansed,  and  then  finally  swab  the  parts  with 
1  in  30  carbolic  solution,  or  1  in  1,000  biniodide  of  mercury  and 
alcohol. 

But  while  it  must  be  admitted  that  a  thorough  cleansing  of  the 
vulva  is  as  important  in  obstetric  practice  as  is  the  thorough  cleansing 
of  the  abdominal  wall  in  surgical  work,  one  cannot  say  the  same 
regarding  the  cleansing  of  the  vagina.  In  recent  years  very  extensive 
investigations  regarding  the  organisms  that  infest  the  vagina  have 
been  made  by  a  number  of  different  observers,  Kronig,  Menge,  Doder- 
lein,  and  Williams  being  specially  worthy  of  mention.  It  certainly 
would  appear  that  the  healthy  vagina  of  pregnant  and  parturient 
women  is  free  of  pyogenic  organisms,  and  that  in  consequence  auto- 
infection  does  not  occur.  But  the  practical  point  is  how  to  know  that 
the  vagina  is  healthy.  Undoubtedly,  when  a  purulent  abundant  dis- 
charge is  present  one  can  say  it  is  not  so,  but  there  are  quite  a  number 
of  cases  in  which  no  one  could  tell,  except  b}^  bacteriological  examina- 
tion, whether  or  not  pyogenic  organisms  were  present.  While  I  am 
certainly  not  an  advocate  of  the  universal  ante-partum  douching  of 
parturient  women,  I  do  think  it  is  a  wise  proceeding  to  wash  out  the 
vagina  carefully  in  all  cases  of  operative  interference,  except  those 
simple  cases  where  the  head  is  at  the  outlet  and  has  simply  to  be 
helped  through  the  vulvar  orifice. 

For  cleansing  the  vagina  it  is  not  sufficient  to  simply  introduce  the 
nozzle  and  wash  out  the  canal.  The  operator  must,  with  his  ringers, 
go  all  over  the  mucous  membrane,  and  this  naturall}7  is  best  done  with 
the  hand  protected  by  a  rubber  glove.     Soft  soap  and  lysol,  I  per  cent. 


PREPARATION  OF  THE  PATIENT  313 

is  the  best  material  for  doing  this, -for.  it  is  not  possible  to  scrub  the 
mucous  membrane  of  the  vagina  with  rough  gauze.  In  quite  recent 
years  ;i  number  of  obstetricians,  including  Ahlfeld,  Hofmeier,  Pinard, 
and  Schauta,  have  been  favouring  the  more  general  cleansing  of  the 
vagina  by  douching  in  labour,  and  their  results  do  not  seem  to  indicate 
that  infection  is  more  frequent.  Indeed,  their  figures,  as  compared 
with  those  of  others  who  have  not  adopted  such  a  course,  are  better, 
as  can  be  seen  by  the  table  given  by  Herff.1  Doderlein's  recent 
investigations  support  the  view  that  the  morbidity  is  lower  in  the  cases 
not  douched. 

Post-partum  douching  I  only  employ  in  cases  of  haemorrhage,  and 
where  the  placenta  or  membranes  have  been  removed  manually,  and 
as  far  as  can  be  judged  at  present  that  is  the  general  attitude  assumed 
towards  douching  after  delivery. 

The  preparation  of  the  abdominal  wall,  when  the  peritoneal  cavity 
has  to  be  opened,  is  a  much  simpler  matter  than  the  cleansing  of  the 
vagina  and  vulva,  and  there  is  no  question  regarding  the  necessity  of 
its  being  thorough.  In  the  Glasgow  Maternity  Hospital,  and  in  private, 
I  prepare  the  abdomen  as  follows  :  If  immediate  operation  is  necessary, 
it  is  washed  with  soap  and  water  and  a  soft  nail-brush  for  five  or  six 
minutes,  and  then  with  turpentine  and  70  per  cent,  alcohol.  After  the 
alcohol  has  been  removed,  a  large  compress,  soaked  in  1  in  20  carbolic, 
is  applied  for  a  quarter  of  an  hour.  This  is  removed,  and  the  skin 
again  cleansed  with  soap  and  water  and  alcohol  immediately  before 
the  operation  begins. 

When  two  or  three  days  are  available  for  preparing  the  patient,  the 
skin  is  treated  differently,  and  I  rely  then  upon  frequent  washings  of 
the  abdomen  with  soap  and  water  and  alcohol,  a  dry  sterilized  dressing 
being  applied  in  the  intervals.  Some  hours  before  the  operation 
a  compress  of  1  in  40  carbolic  is  applied,  and  on  the  operating-table, 
before  proceeding  to  open  the  abdomen,  my  assistant  goes  over  the  skin 
again  with  soap  and  water  and  alcohol. 

Since  I  adopted  these  methods  of  cleansing  the  skin  and  of 
cleansing  the  hands,  and  since  I  and  my  assistants  and  nurses  have 
used  gloves,  it  is  most  exceptional  to  get  any  stitch  abscess  in  cases  in 
which  the  operation  was  undertaken  for  non-septic  conditions.  I 
must  admit,  the  patient  has  once  or  twice  suffered  from  carboluria.2 

In  addition  to  all  the  precautions  taken  against  infection  which 
have  been  already  detailed,  the  lower  bowel  and  bladder  should  be 

1  Winckel's  'Handbuch,'  1906,  Bd.  iii.,  Teil  ii.,  792. 

2  In  a  series  of  hospital  cases  Dr.  Dickie  and  I  employed  acetone  and  iodide  for 
skin  preparation.  The  results  were  not  altogether  satisfactory,  so  that  I  have 
returned  to  the  carbolic  dressings  mentioned. 


31  l  OPERATIVE  MIDWIl'KliV 

evacuated.  The  bladder,  <>f  course,  is  easily  emptied  by  a  catheter  if 
the  patient  cannot  evacuate  it  herself.  It  is  a  good  rule,  however,  to 
use  the  catheter  as  little  as  possible,  for,  in  spite  of  every  precaution 
taken  against  conveying  organisms  into  the  bladder,  these  latter  are 
sometimes  carried  in  and  slight  cystitis  set  up.  It  is  my  custom, 
therefore,  in  all  cases  where  the  catheter  has  to  be  frequently  pa>- 
after  operation,  to  put  the  patient  on  small  doses  of  urotropin  and  to 
run  into  the  bladder  2  or  8  ounces  of  weak  boracic  solution  after  each 
catheterization.  1  feel  sure  that  since  J  have  adopted  these  prophy- 
lactic measures  vesical  catarrh  has  been  less  frequent. 

When  time  permits,  the  bowels  should  be  thoroughly  evacuated  by 
a  full  dose  of  castor  oil  or  some  other  laxative,  but  in  obstetric  prac- 
tice one  frequently  has  not  time  to  do  this,  and  so  has  to  be  content 
with  clearing  out  the  lower  bowel  by  means  of  a  soap  and  water 
enema. 

Prior  to  any  operation  necessitating  the  administration  of  chloro- 
form the  diet  of  the  patient  should  be  restricted,  but  in  obstetric 
practice  this  is  seldom  practicable.  There  is  no  doubt  that  careful 
dieting,  and  especially  the  establishment  of  a  good  diuresis  before  the 
administration  of  chloroform,  lessens  the  sickness  which  so  commonly 
follows  the  administration  of  an  anaesthetic. 

Anaesthetics  in  Parturition. 

The  anaesthetic  employed  in  obstetric  practice  in  this  country  is 
almost  exclusively  chloroform.  It  is  very  easily  administered,  and.  - 
every  one  admits,  is  most  safe  in  pregnancy  and  parturition.  In  spite, 
however,  of  what  may  be  said  to  the  contrary,  chloroform  does  favour 
post-partum  haemorrhage,  and  very  decidedly  so  if  the  administration 
has  been  continued  for  any  length  of  time,  and  surgical  anaesthesia  has 
been  induced.  In  my  experience  chloroform  distinctly  inhibits  retrac- 
tion of  the  uterus  after  the  birth  of  the  child.  The  amount  of  haemor- 
rhage may  not  be  of  any  consequence,  but  the  ballooning  up  of  the  ut< 
with  blood- clot  accumulating  between  the  membranes  and  placenta  and 
uterine  wall  interferes  with  the  natural  separation  and  expulsion  of  the 
placenta,  and  so  favours  laceration  and  retention  of  portions  of  the 
membranes.  Some  may  say  that  this  latter  complication  is  the  result 
of  the  accoucheur  hastening  the  delivery  of  the  placenta,  which  he  is 
probably  tempted  to  do  in  cases  where  anaesthesia  has  been  prolonged. 
I  am  quite  satisfied,  however,  that  is  not  the  full  explanation,  for  I 
have  given  the  placenta  infinite  time  to  separate  and  be  expelled,  and 
yet  have  had  trouble  with  retained  membranes. 

The  effect  of  chloroform  upon  the  parturient  varies  ;  sometimes  it 


AN/ESTHETICS  IN  PARTURITION  315 

distinctly  inhibits  the  uterine  contractions  even  when  given  in  small 
amount,  but  on  other  occasions,  especially  if  the  parturient  is  nervous 
and  excited,  small  doses,  by  quieting  her  or  by  removing  some  reflex 
irritation,  act  as  a  stimulant  to  the  uterus.  Every  one  is  familiar  with 
the  relaxation  that  follows  the  administration  of  chloral  or  chloroform 
if  the  soft  parts  are  unduly  rigid. 

As  regards  the  child,  there  is  only  danger  to  it  when  the  anaesthesia 
is  very  prolonged.  It  is  quite  certain,  however,  that  a  considerable 
amount  of  the  anaesthetic  gets  into  the  child's  circulation,  for  it  is 
frequently  very  drowsy  for  some  time  after  its  birth. 

Spinal  Anaesthesia. — Since  the  introduction  of  spinal  anaesthesia 

secured  by  the  injection  of  1  to  12  grammes  of  a  sterilized  2  per  cent. 

solution  of  cocaine  into  the  spinal  cavity,  other  preparations,  such  as 

eucaine,  stovaine,  novocaine,  etc.,  are  under  experimental  trial.     The 

following  is  Bier's  formula  : 

Stovaine 0-04  gramme. 

Adrenalin  0-00013  „ 

Sodium  chloride  0-0011     „ 

Distilled  water 2-0  grammes. 

Thus,  each  dose  contains  4  centigrammes  of  stovaine. 

The  skin  being  sterilized,  a  long,  hollow  needle  is  introduced  into 
the  spinal  cavity  at  a  point  between  the  third  and  fourth  lumbar 
vertebrae,  half  an  inch  to  either  side  of  the  middle  line.  The  needle  is 
pushed  in  an  upward  and  inward  direction,  and  the  escape  of  a  few 
drops  of  cerebro-spinal  fluid  indicates  that  the  spinal  cavity  has  been 
reached.  The  syringe  containing  the  solution  is  now  attached  to  the 
needle,  and  about  1  c.c.  of  cerebro-spinal  fluid  allowed  to  mix  with  the 
stovaine  solution.  The  fluid  is  then  slowly  injected.  The  puncture 
is  sealed  with  sterilized  collodion.  In  the  few  cases  in  which  I  have 
employed  spinal  anaesthesia  I  have  been  thoroughly  satisfied. 

Scopolamine  and  Morphine. — In  the  last  few  years  hypodermic 
injections  of  scopolamine  and  morphine  have  been  extensively 
employed  in  parturition.  Speaking  generally,  the  results  have  been 
fairly  satisfactory.  Some  writers  have  referred  to  the  injurious  effect 
on  the  foetus,  and  nearly  all  are  agreed  that  they  slightly  retard  the 
progress  of  labour.  As  far  as  one  can  judge,  they  do  not  very 
appreciably  predispose  to  post-partum  haemorrhage.  Although  the 
injections  may  be  employed  during  any  stage  of  labour,  in  most  cases 
it  is  preferable  to  use  them  only  in  the  second  stage ;  but  in  a  very 
prolonged  first  stage  I  have  seen  no  ill  effect  follow  the  administration 
of  the  drugs.  Speaking  generally,  the  most  suitable  initial  dose  is 
inyo-  grain  of  scopolamine,  with  J  grain  of  morphine ;  if  need  be, 
this  can  be  repeated.  The  amount  of  the  second  dose  should  be 
gauged  by  the  general  and  mental  condition  of  the  patient. 


CHAPTEIi  XXII 

VERSION,  OR  TURNING 

In  this  chapter  I  will  only  discuss  the  methods  of  performing  version, 
us  the  manner  of  extracting  the  child  and  the  difficulties  in  doing 
this  have  been  already  considered  in  Chapter  V. 

The  operation  of  version  has  for  its  object  the  substitution  of  the 
head  or  the  feet  for  some  other  presenting  part.  If  the  head  is 
brought  to  present,  we  speak  of  'cephalic'  version:  while  if  a  lower 
limb  is  brought  down  we  speak  of  '  podalic  '  version.  It  is  of  extreme  lv 
ancient  date,  and  was  extensively  practised  by  Hippocrates,  who 
recommended  cephalic  version  for  all  presentations  other  than  those 
of  the  head.  .Etius,  Celsus  and  others,  at  different  times,  pointed 
out  the  fallacies  of  the  Hippocratic  teaching  and  the  advantages  of 
podalic  version  ;  but,  supported  by  Galen,  it,  for  the  most  part, 
continued  in  favour  till  the  sixteenth  century,  the  one  ever  famous 
in  obstetrics  by  reason  of  the  great  revival  in  midwifery  initiated  by 
Ambrose  Pare.  Pare  was  the  first  to  clearly  describe  and  point  out 
the  possibilities  and  advantages  of  podalic  version,  and  from  his  time 
until  the  obstetric  forceps  became  common  property  podalic  version 
was  widely  practised  in  cases  where  immediate  delivery  was  deemed 
necessary.  About  a  hundred  years  later  an  alteration  in  the  technique 
of  the  operation  was  suggested  by  Portal — viz.,  the  bringing  down  of 
one  leg  instead  of  both,  as  was  the  custom  up  till  then;  but,  apart 
from  that,  there  was  no  great  modification  of  the  operation  until 
1807,  when  Wigand  described  and  recommended  version  by  external 
manipulations. 

But  even  such  a  brief  reference,  as  this  one  is,  to  the  history 
of  version  would  be  incomplete  did  I  not  mention  the  name  of  Braxton 
Hicks,  who  will  ever  be  honoured  on  account  of  his  method  of  version 
by  combined  internal  and  external  manipulations,  which  he  described 
in  18G0.1  Full  details  of  the  operation  are  also  to  be  found  in  the 
London  Obstetrical  Society's  Transactions,2  in  the  Appendix  to  which 
paper  Hicks  justifies  his  claim  to  having  first  clearly  described  this 

1  Lancet,  July  14,  1860.  -  Vol.  v.,  p.  219. 

316 


VERSION,  OR  TUENING  317 

method  of  version.  It  is  perfectly  true -Wigand  suggested  the  employ- 
ment of  one  hand  internally,  but  his  reference  to  that  hand  is  so 
casual  that  it  is  impossible  to  believe  that  he  really  meant  it  to  be 
much  used.  Hohl,  Wright,  Schmidt,  Lee,  and  others,  referred  to 
similar  manipulations  ;  but  Hicks,  by  reason  of  the  clear  manner  in 
which  he  described  all  details,  really  deserves  the  greatest  credit. 

In  certain  conditions  the  operation  of  version  is  one  of  choice  :  in 
others,  it  is  the  only  course  open.  In  transverse  presentations,  for 
instance,  it  is  the  only  treatment  to  be  considered ;  but  in  placenta 
prsevia,  accidental  haemorrhage,  contracted  pelvis,  accouchement  force" 
for  any  danger  threatening  the  mother,  it  may  be  said  to  be  an  opera- 
tion of  choice.  The  position  it  occupies  in  the  treatment  of  these 
conditions  is  discussed  in  detail  when  each  is  being  considered.  Here 
I  shall  simply  summarize  the  matter. 

The  indications  for  the  operation  of  version  may  be  placed  in  the 
following  groups : 

1.  Malpositions  and  Malpresentations  of  the  Child. — In  all 
transverse  presentations,  and  in  brow  and  face  presentations  under 
certain  conditions,  version  is  indicated.  Mento-posterior  face  and 
brow  presentations,  recognized  early  in  labour,  are  considered  by 
many  to  be  best  treated  by  version,  although  a  few  favour  the  altera- 
tion of  the  presentation  into  an  ordinary  vertex  by  the  method  of 
Thorn  (p.  39).  In  recent  years  quite  a  number  of  obstetricians 
(Pinard,  Hegar,  Spencer)  have  expressed  themselves  in  favour  of 
converting  a  breech  into  a  vertex  presentation  by  external  version. 
I  have  frequently  done  this  in  the  last  two  weeks  of  pregnancy,  and, 
personally,  am  of  opinion  that  it  is  sound  treatment.  It  is  incorrect 
to  say  that  one  makes  the  presentation  worse  and  brings  about  a 
transverse  if  one  fails,  for  when  the  foetus  cannot  be  completely  turned 
it  can  always  be  pushed  back  into  its  old  presentation.  The  object 
of  the  treatment  is  to  lessen  the  foetal  mortality,  which,  in  primiparse 
especially,  is  very  high.  It  is  quite  absurd  for  those  who  are 
opposed  to  this  treatment  to  say  that  it  is  a  reversion  to  the  treat- 
ment of  Hippocrates,  for  Hippocrates  performed  the  operation  during 
labour,  and  with  his  hand  in  the  uterus. 

2.  Flat  Pelvis. — Personally,  I  do  not  consider  a  flat  pelvis  an 
indication  for  version,  except  in  cases  of  scolio-rachitic  pelvis  where 
the  occipital  end  of  the  head  is  towards  the  small  side  of  the  pelvis, 
and  in  posterior  parietal  presentations.  The  subject  is  fully  con- 
sidered in  connexion  with  contracted  pelvis  (Chapter  XII.). 

3.  Dangers  threatening-  the  Mother. — Amongst  these  the  most 
striking  are  placenta  prasvia  and  accidental  hemorrhage.  As  a  step 
in  the  operation  of  accouchement  force  it  is  also  frequently  performed. 


318  OPERATIVE  MihVYll  Ki;Y 

\  ery  occasionally  fche  operation  is  necessary  in  displacements  of  the 
uterus  and  in  doable  monsters  (Chapters  XIX.  and  J\.). 

1.  Dangers  threatening-  the  Child.     Prolapse  of  the  cord  is  the 
most  important  indication  under  this  head.     The  subject,  however, 
discussed  under  Prolapse  of  the  Cord  (Chapter  XX.). 

There  are  three  methods  of  performing  version,  by  any  one  of  which 
the  head  (cephalic  version)  or  the  lower  limhs  (podalic  version)  may 
he  brought  to  present.  These  are  :  (1)  JJv  purely  internal  manipula- 
tions—Internal version:  (2)  by  purely  external  manipulations — I 
ternal  version  :  (8)  by  combined  internal  and  external  manipulations 
— Bipolar  version,  or  version  after  the  method  of  Braxton  Hicks. 
Each  of  these  methods  we  must  now  consider,  hut  before  doing  so  a 
word  regarding  the  relative  merits  of  cephalic  and  podalic  version. 

As  previously  stated,  until  the  middle  of  the  sixteenth  century 
cephalic  version  was  almost  exclusively  practised.  As  a  result  of 
Fare's  teaching,  podalic  version  came  into  favour,  and  completely 
replaced  cephalic.  Following,  however,  the  great  improvements 
of  Wigand,  Hicks,  and  others,  cephalic  version  has  once  again 
come  more  into  favour.  The  method  is  suitable  for  rectifying  oblique 
presentations,  and  even  breech  presentations,  recognized  early  in 
labour.  It  is,  however,  not  suitable  for  cases  of  hamorrhage,  and 
the  majority  of  obstetricians  would  also  say  that  it  was  not  suitable 
for  cases  of  contracted  pelvis.  Personally,  however,  I  have  frequently 
changed  a  breech  into  a  head  in  cases  of  moderate  pelvic  deformity, 
for  I  believe  the  chances  to  the  child  are  infinitely  better  if  it  comes 
head  first. 

Internal  Version. 

This  is,  as  we  have  seen,  the  oldest  method.  For  its  performance 
the  os  must  be  sufficiently  dilated  to  allow  of  the  introduction  of  the 
hand.  The  vulva,  lower  abdomen,  and  upper  parts  of  the  thighs, 
having  been  thoroughly  cleansed,  and  the  bladder  and  rectum  emptied, 
the  patient  is  ready  for  operation.  She  should  then  be  brought  to  the 
edge  of  the  operating-table  or  bed,  and  have  the  vagina  thoroughly 
washed  out. 

The  position  of  the  patient  during  the  operation  may  be  either  the 
dorsal  or  the  left  lateral,  but  on  the  whole  the  lateral  position  is 
better  :  at  least,  that  is  so  in  cases  where  the  child  lies  dorso-posterior 
in  the  uterus.  When  the  child  lies  dorso-anterior,  the  left  lateral 
position  is  of  slight  advantage  only  if  the  operator  is  ambidextrous 
and  can  use  his  left  hand,  which  adapts  itself  better  than  the  right  to 
the  curve  of  the  sacrum  (Fig.  18(1).  Another  advantage  of  the  lateral 
position,  especially  if  the  patient  is  rolled  well  round  on  her  breast,  is 


VERSION,  OR  TURNING 


319 


that  the  presenting  part  slips  away  by  gravity  from  the  brim  ;  this 
allows  the  hand  to  be  passed  into  the  uterus  more  readily.  After  the 
foot  has  been  seized,  and  extraction  has  to  be  proceeded  with,  the 
dorsal  position  is  more  suitable,  as  one  can  employ  the  external  hand 
better  in  conjunction  with  the  internal  when  the  patient  is  in  that 
position.  If  one  employs  the  dorsal  position  from  the  first,  it  is  better 
to  seize  the  limb  or  limbs  with  the  hand  which  corresponds  to  the  side 
the  limbs  are  on.  That  is  to  say,  if  the  limbs  are  on  the  left  side,  one 
employs  the  right  hand  ;  if  they  are  on  the  right,  the  left  hand. 


Fig.    136. — Internal  Version,    showing   the   Advantage   of  using   the   Left   Hand,   as   it 
accommodates  itself  better  than  the  Right  to  the  Curve  of  the  Sacrum. 


But  much  more  important  than  the  position  of  the  patient,  which, 
after  all,  is  very  much  a  matter  of  choice,  is  that  the  patient  be 
anaesthetized  before  any  attempts  at  version  are  made.  Especially 
does  this  apply  to  the  operation  of  internal  version  when  the  waters 
have  drained  away.  Much  injury  is  done  by  the  operator  getting 
excited  and  pushing  his  hand  into  the  parturient  canal  when  the 
patient  is  only  half  under  the  anaesthetic. 

When  the  operator  has  determined  that  his  whole  hand  is  to 
be  introduced  into  the  uterus,  he  should  separate  the  labia  with  the 
fingers  of  the  one  hand,  and  cautiously  pass  the  other  hand  in  the 
form  of  a  cone  up  towards  the  feet,  keeping  the  back  of  the  hand 


320  OPERATIVE  Mll>\VII'i;i;Y 

directed  against  the  uterine  wall.     The  hand  should  be  passed  right 

through   the   membranes  if  they   are   -'ill   intact:   the   forearm   dams 
back  the  liquor  amnii.     Thia  is  much  better  than  passing  the  hand  up 

between  the  membranes  and  uterine  wall  until  the  limb  is  reached, 
used  tu  be  the  teaching,  because  by  so  doing  there  is  greater  danger 
of  infection,  seeing  that  any  organisms  present  are  implanted  upon  the 
raw  uterine  surface  instead  of  inside  the  amnionic  Bac.      From  tim< 
time  during  uterine  contractions  all  manipulations  musl  be  desisted 
from,  and  the  open  hand  allowed  to  lie  passively  against  the  surl 
of  the  child. 

There  is  seldom  much  difficulty  in  getting  hold  of  a  foot  ;  indeed, 
it  only  occurs  when  the  waters  have  drained  away,  and  the  child  is 
grasped  and  doubled  up  by  the  contracting  uterus.  In  such  cases  it 
will  generally  be  found  best,  instead  of  getting  mixed  up  with  limbs 
all  huddled  together,  to  pass  the  hand  right  up  to  the  breech,  and 
come  back  along  a  thigh  and  seize  one  or  both  feet. 

It  sometimes  happens,  in  cases  in  which  the  waters  have  long 
drained  away  and  the  uterine  wall  is  closely  applied  to  the  child,  that 
the  child  is  more  readily  turned  if  both  feet  are  seized. 

The  difficulty  of  differentiating  a  foot  from  a  hand  is  not  great.  A 
foot  is  always  to  he  distinguished  from  a  hand  b}7  the  presence  of  the 
heel  ;  other  differences,  such  as  the  length  of  fingers,  mobility  of 
thumb,  etc.,  are  not  to  be  relied  upon.  The  heel  is  the  landmark  one 
should  search  for ;  never  bring  down  a  limb  until  the  heel  is  felt. 

Having  reached  the  lower  limbs,  one  foot  is  seized,  or  both.  A.fl 
stated  elsewhere,  Pare  and  Guillemeau  recommended  the  bringing 
down  of  both  feet,  and  that  continued  to  be  the  practice  for  nearly  two 
centuries,  even  although  Portal,  in  the  middle  of  the  seventeenth 
century,  clearly  demonstrated  the  advantage  of  bringing  down  only 
one.  It  is  only  in  comparatively  recent  times  that  it  has  been  the 
general  practice  to  bring  down  one  foot.  I  have  already  pointed  out 
the  advantages  of  doing  so  (Chapter  V.),  and  have  recommended  that 
only  when  the  delivery  has  to  be  completed  with  all  speed  should  both 
be  seized. 

Theoretically,  it  is  not  altogether  a  matter  of  indifference  which 
foot  one  takes,  although  in  practice  I  must  admit  it  is  a  good  enough 
rule  to  grasp  the  first  foot  one  encounters.  In  all  cranial  presentations 
the  anterior  leg  is  the  one  to  seize.  This  holds  good  also  in  transverse 
presentations  when  the  back  of  the  child  is  anterior,  hut  not  in  dorso- 
posterior  positions:  then  the  posterior  or  superior  leg  is  preferable. 
A  good  working  rule,  therefore,  is  :  Seize  the  nearest  foot  in  (til  cases 
except  oblique  dorso-posterior  positions.  The  advantage  of  following 
•this   rule    is    that   the   anterior   leg   is    brought   down    against   the 


VERSION,  OR  TURNING 


321 


symphysis,  whereas  if  one  took  the  other  foot,  one  would  bring  down 
the  posterior  leg,  and  the  anterior  buttock  would  catch  on  the 
symphysis,  which  we  have  already  seen  (Fig.  28)  is  a  great  dis- 
advantage and  causes  delay  in  extracting  the  breech. 

The  foot,  being  seized,  should  be  brought  down  through  the  cervix. 


Fig.  137. — Internal  Version. 

Version  is  Vicing  completed.  The  accoucheur  is  pulling  down  the  leg,  while  his  assistant  is 
pulling  up  the  head.  It  will  be  observed  that  he  has  seized  the  leg  farthest  away, 
because  the  position  is  an  oblique  dorso-posterior  one. 

The  carrying  of  this  out  is  often  facilitated  by  an  assistant  pushing  or 
pulling  up  the  head  (Fig.  137).  The  operator  may  himself  do  this,  but 
his  spare  hand  is  better  employed  steadying  and  pushing  down  the 
breech,  for  the  external  hand  should  always  act  in  consort  with  the 
internal. 

The  operation  of  version  is  seldom  difficult  if  the  membranes  are 

•21 


322 


Ol'KIIATIVK  MIDWIFERY 


intact  or  have  only  recently  ruptured.  It  becomes  increasingly 
difficult  and  dangerous,  however,  after  the  liquor  iimnii  has  drained 
away,  and  great  caution  must  be  exercised  in  attempting  the  operation 
in  such  cases.     It  must  never  be  performed  in  head  presentations  if 


Mm 


FlG.  138. — Internal  Version. 

A  fillet  has  been  passed  round  the  prolapsed  arm,  in  order  to  prevent  it  slipping  up  after 
version  is  completed.  The  accoucheur  is  seizing  hold  of  a  foot — the  wrong  one  in  this 
particular  position  of  the  foetus  (see  text). 

the  retraction  ring  is  well  defined,  nor  in  cases  of  impacted  transverse 
presentation  ;  forceps  or  craniotomy  in  the  former  and  decapitation  in 
the  latter  are  the  operations  which  should  be  had  recourse  to. 

In   transverse   or   oblique    presentations   the  lower  arm    not   in- 


VERSION,  OR  TURNING  323 

frequently  prolapses.  The  particular  arm  can  always  be  recognized 
by  shaking  hands  with  the  child  (Fig.  54).  When  the  arm  has 
prolapsed,  it  may  sometimes  be  pushed  up,  but  this  is  often  impossible 
and  quite  unnecessary,  for  the  arm  slips  up  as  the  leg  is  pulled  down. 
A.  very  useful  manoeuvre  is  to  apply  a  loop  of  gauze  round  the  wrist  of 
the  foetus  (Fig.  138).  In  doing  so  care  must  be  taken  not  to  fasten  it 
too  tightly.  This  loop  of  gauze  or  fillet  so  applied  is  of  great  service 
later  in  the  labour  in  preventing  the  arm  from  slipping  up  along  side 
of  the  head.  It  must  only  be  used  to  prevent  the  arm  slipping  up. 
If,  however,  in  spite  of  all  one's  efforts,  the  arm  should  slip  up,  it 
must  be  brought  down  in  the  ordinary  way  and  not  by  pulling  upon 
the  gauze,  for  that  might  result  in  its  fracture. 

It  sometimes  happens,  especially  when  the  waters  have  drained 
away,  and  there  is  difficulty  in  turning  the  child,  that  version  is 
facilitated  by  a  manoeuvre  generally  ascribed  to  Siegemundin.  It 
consists  in  passing  a  fillet  over  the  foot  and  then  exerting  traction  on 
the  fillet  with  the  one  hand,  while  the  other  hand  is  passed  into  the 
vagina  and  pushes  up  the  presenting  shoulder  or  head  (Fig.  139). 
"When  such  a  manipulation  is  necessary,  it  usually  means  that  the 
uterus  is  firmly  retracted  over  the  child,  and  so  the  operation  is  not 
free  of  danger.  An  alternative  to  this  method  is  the  bringing  down 
of  the  other  foot,  which  will  usually  be  found  behind  the  one  already 
brought  down. 

In  attempting  to  bring  down  the  second  foot  the  hand  must  be 
passed  cautiously  into  the  uterus  behind  or  in  front  of  the  leg  already 
down,  according  as  it  is  the  anterior  or  posterior  one  which  is  present- 
ing. In  cases  of  doubt  one  can  readily  determine  which  foot  is  down 
from  the  position  of  the  great  toe.  With  the  two  feet  together  the 
great  toes  are  in  apposition.  Both  feet  being  seized  and  steady  trac- 
tion made  upon  them,  version  can  generally  be  completed,  unless  the 
uterus  is  grasping  the  child  very  firmly. 

As  can  readily  be  understood,  a  great  strain  is  put  upon  that  part 
of  the  uterus  against  which  the  head  rests  during  these  manoeuvres, 
and  especially  is  this  the  case  when,  labour  having  been  long  in 
progress,  the  lower  uterine  segment  is  much  thinned  out.  Either  of 
the  manoeuvres,  if  carried  out  very  cautiously,  will  result  in  the  safe 
delivery  of  the  child  without  any  damage  being  done  to  the  mother, 
provided  the  head  is  within  the  body  of  the  uterus.  Should,  however, 
the  head  be  in  the  lower  segment  below  the  retraction  ring,  there  is 
the  greatest  possible  danger  in  employing  either  of  them,  but  more 
especially  the  second.  Indeed,  I  would  almost  go  to  the  length  of  saying 
that  they  are  never  justifiable,  because  of  the  great  danger  of  the 
uterus  and  vagina  being  ruptured.     Besides,  they  are  almost  profit- 


324 


OPERATIN  E  MIDWIFERY 


ess,  as  tlif  child  is  dead,  or  on  the  point  of  dying  in  the  vast  majority 
of   cases. 

I  am  well  aware  that  Binlin  and  others  have  reconini>  inl«-<l  in  such 


Fig.  139.-  Interna]  Version. 

A  manoeuvre  sometimes  i  mployed  when  there  is  difficulty  in  c<.ii i ] >l.-t in.u.  version.  A  fillet 
has  been  passed  round  the  leg  which  has  been  broughl  down.  The  accoucheur  pulls 
upon  this,  while  with  his  < >t  lier  hand  he  pushes  up  the  head  01  shonldi  r. 


cases,  when  the  head  is  helow  the  retraction  ring,  that  the  hand 
should  be  passed  up  between  the  uterine  wall  and  the  child's  head, 
the  retraction  ring  pushed  back  and  the  child's  head  allowed  to  glide 


VERSION,  OB  TUKNING 


825 


out  of  the  lower  segment.  I  have  succeeded  in  doing  this  under  deep 
anaesthesia,  but  it  is  a  mamcuvre  very  often  impossible,  and,  unless 
one  has  had  extensive  practice  in  difficult  obstetric  operations,  is 
attended  with  considerable  danger. 

Internal  cephalic  version,  the  operation  of  Hippocrates  and  his 
disciples,  has  practically  been  given  up.  If  by  any  chance  it  should 
be  deemed  advisable  to  have  recourse  to  it,  the  head  should  be 
grasped  and  pulled  down  while  the  breech  is  pushed  up  to  the 
fundus  by  the  external  hand. 


Fig.   140. — External  Cephalic  Version. 
The  accoucheur  has  located  the  head  with  the  right  and  the  breech  with  the  left  hand. 


External  Version. 

Following  strictly  in  chronological  order,  we  have  now  to  consider 
the  method  of  version  known  as  External  Version.  To  Wigand,  as 
we  have  seen,  is  due  the  credit  of  first  describing  this  method, 
although  others  had  undoubtedly  long  before  casually  referred  to  it. 

It  is  an  operation  possible  only  under  favourable  conditions.  If 
the  membranes  have  ruptured,  if  the  liquor  amnii  is  very  scant}7,  and 
if  the  uterine  wall  is  so  rigid  that  the  foetal  parts  cannot  be  grasped, 
external  version  is  impossible.  After  some  experience  of  the  opera- 
tion, however,  it  is  surprising  how  comparatively  seldom  such  con- 
ditions are  encountered  in  pregnancy.  Even  at  term  in  multiparas 
one  can  often  perform  it ;    but  in  prinriparae  it  is  always  difficult 


826 


OPERATIVE  MIDWIFERY 


and  often  impossible.    The  operation  has  this  advantage — it  can  be 

performed  early  in  lahour  or  even  during  pregnancy  before  the  cervix 
is  obliterated,  and  I  have  apon  several  occasions  convened  breech 
into  cranial  presentations  at  the  thirty-sixth  or  thirtli-seventh  week 
by  this  method.  So  niiicd),  indeed,  am  1  in  favour  of  this  form  of 
version  that  in  many  ca>es  in  which  version  by  Braxton  [licks' 
method  might  be  chosen — as,  for  example,  in  placenta  pra  via — I 
actually  perform  the  operation  by  external  manipulations,  and  only 
employ  the  fingers  in  the  vagina  to  pull  down  a  foot  after  the  breecfa 
has  been  brought  over  the  os. 


Fig.  141. — External  Cephalic  Version. 

The  accoucheur  is  pushing  the  foetal  head  downwards  with  his  right  hand,  while  he  is 
pulling  the  breech  upwards  with  his  left. 


In  some  women,  more  especially  multipara?,  the  operation  may  he 
performed  without  an  anaesthetic ;  but  if  the  patient  is  a  primipara, 
has  rigid  abdominal  and  uterine  walls,  and  has  reached  term,  an 
anaesthetic  is  usually  necessary.  It  will  generally  be  found  best  to 
have  the  patient  lying  upon  her  back,  with  the  shoulders  slightly 
raised,  although  sometimes  lying  upon  one  or  other  side  helps  a  little 
the  rotation,  and  certainly  favours  dislodgment  of  the  lower  pole. 
This  postural  treatment,  the  principle  of  which  is  to  place  the  mother 
on  the  side  to  which  the  head  or  the  breech  is  directed,  according 
as  one  wishes  a  head  or  a  breech  presentation,  is  occasionally  of  value. 


VERSION,  OK  TURNING 


:>>-±l 


The  first  step  in  the  operation  after  the  patient  has  been 
anaesthetized  is  to  carefully  palpate  the  position  of  the  different 
parts  of  the  child  (Fig.  140).  After  that  has  been  done,  occasionally 
all  one  has  to  do  to  alter  the  presentation  is  to  grasp  one  end  of  the 
fcetal  ovoid  with  each  hand,  and  pull  one  pole  and  push  the  other  in 
the  direction  wanted  (Fig.  141).  To  succeed  in  turning  the  child  as 
easily  as  that  is  exceptional.  As  a  rule,  an  assistant  is  necessary. 
The  operator  and  assistant  stand  facing  each  other,  and  it  is  an 
advantage   that  they   should  be  on   different   sides   of   the   patient. 


Fig.  142. — External  Cephalic  Version. 

In  cases  of  difficulty  the  accoucheur  uses  his  two  hands  to  drag  the  one  fcetal  pole  upwards, 
while  his  assistant  pulls  down  the  other  pole. 


Each  takes  an  end  of  the  fcetal  ovoid  and  pulls  it  towards  himself 
(Fig.  142).  Sometimes,  however,  the  child  is  turned  best  by  reversing 
this  and  pushing  the  part  away,  or  even  by  operator  and  assistant 
facing  the  patient  and  pulling  down  and  pushing  up  the  end  each  is 
responsible  for.  The  position  of  the  child  will  usually  indicate  the 
direction  in  which  pressure  is  to  be  exerted.  In  transverse  presenta- 
tion always,  and  generally  in  all  cases  where  one  pole  is  substituted 
for  another,  it  will  be  found  that  the  child  slides  round  best  when 
pushed  in  the  shortest  way  to  the  desired  position.  Once  or  twice, 
however,  I  have  found  the  child  go  round  better  when  rotated  in 
the  longest  way.     One  thing,   of  course,  must   be  remembered — no 


828 


OPERATIVE  MIDWIFERY 


manipulations    must    be   made   which    would    tend    to    extend    the 
child. 

Saving  turned  the  child,  one  must  try  to  maintain  it  in  the 
favourable  position  in  which  it  1ms  been  placed.  Unfortunately,  how- 
ever, this  is  not  always  possible,  especially  if  the  previous  presenta- 
tion has  been  transverse.     Where  ii  has  been  Longitudinal,  it  is  not  so 


V 


Fig.  143. — Bipolar  Version. 

The  accoucheur,  with  one  or  two  fingers  of  the  one  hand  through  the  cervix,  is  poshing  th< 
head  away  from  the  pelvic  brim,  while  with  Ids  other  hand  he  is  pushing  down  the 
breech. 


difficult.  If  it  is  the  head  which  has  been  made  to  present,  then  it 
should  be  pushed  down  into  the  pelvis  and  a  firm  binder  applied.  If 
the  patient  is  in  labour,  it  is  well  to  rupture  the  membranes. 

A   very   interesting   paper   on    the    subject   of   External   Version 
was  delivered  recently  by  Pollock  to  the  London  Obstetrical  Society.1 

1  Lond.  Ohstet.  Trans.,  vol.  xlviii.,  for  1906. 


VERSION,  Oil  TURNING 


329 


This  author,  although  admitting  the  difficulties  and  frequent  failures 
of  external  version,  referred  to  the  method  in  very  favourable  terms, 
and  stated  that  he  had  found  the  Trendelenburg  position  of  great 
advantage.  Carried  out  in  this  position,  he  referred  to  the  method 
as  '  fundal  external  version.'  As  Spencer  pointed  out  in  the  discussion 
which   followed,   postural  treatment  is  of   great  antiquity.      I  have 


Fig.  144. — Bipolar  Version. 

A  further  step  in  the  operation.     The  head  and  shoulder  of  the  fetus  are  being  pushed 
away  with  the  internal  hand,  while  the  breech  is  being  pushed  dowu  with  the  external. 

repeatedly  referred  to  the  advantages  of  the  Sims  position  in  certain 
cases,  where,  for  example,  one  wishes  to  dislodge  the  presenting  part 
from  the  pelvis. 

Bipolar  Version. 

This  method,  as  we  have  seen,  was  elaborated  and  perfected  by 
the  late  Braxton  Hicks,  and  the  operation  is  very  rightly  referred 
to  under  his  name.  One  may  bring  either  the  head  or  the  breech 
to   present.      The   illustrations   indicate   the   manner    in   which    the 


880 


OPERATIVE   MIDWIFERY 


manipulations  are  carried  oat.  It  is  better  to  have  the  patient  upon 
ber  back  and  anfesthetized.    The  parte  about  the  vulva  having  been 

thoroughly  cleansed,  the  suitable  hand  is  introduced  into  the  vagina 
and  two  lingers  arc  passed  through  the  cervix  (Fig.  148).  These 
push  the  presenting  part  away,  while  the  external  hand  presses  or 
pulls  down  the  other  total  pole  (Fig.  111).  It  is  important  to  employ 
the  suitable  hand  internally,  so  that  the  arms  are  not  crossed  during 


Fig.  145.— Bipolar  Version. 
The  feet  of  the  foetus  having  been  brought  over  the  os,  the  accoucheur  is  now  able  to  sei:  ■ 


the  manipulations.  An  assistant  can  often  render  great  help  by 
pulling  up  the  pole  which  is  being  pushed  away  by  the  operator's 
internal  hand. 

In  order  to  carry  out  the  operation,  the  foetus  must  be  fairly 
movable  in  the  uterine  cavity ;  consequently,  the  membranes  must  be 
unruptured,  or  only  recently  ruptured,  and  the  os  must  be  dilated  to 
permit  at  least  one  finger  being  passed  through  the  cervix.  It  is 
surprising  how  occasionally,  long  after  rupture  of  the  membranes, 
it  is  still  possible  to  perform  version  by  Hicks'  method.     When  the 


VERSION,  OR  TURNING 


:■$:!! 


feet  are  brought  over  the  os,  one  should  be  pulled  down  into  the 
vagina  (Fig.  145).  There  is  sometimes  a  little  difficulty  in  getting 
hold  of  the  foot,  but  the  external  hand,  by  steadying  and  pushing 
the  leg  down,  will  generally  bring  it  within  reach  of  the  internal 
fingers  (Fig.  146).  Personally,  I  do  not  care  to  bring  down  the  leg 
by  hooking  my  finger  into  the  bend  of  the  knee,  for,  if  the  presenta- 
tion has  been  originally  cranial,  it  is  not  easy  to  make  sure  that  it  is 


Fig.  146. — Bipolar  Version. 
The  accoucheur,  having  seized  the  foot,  is  bringing  it  down  through  the  vulva. 


the  leg  which  is  over  the  internal  finger.  I  never  like  to  bring  down 
a  limb  in  such  cases  until  I  feel  the  heel.  With  one  finger  only 
through  the  cervix,  the  foot  is  not  easily  brought  down,  but  by 
getting  it  over  the  os,  then  suddenly  withdrawing  the  finger  in 
the  cervix,  it  will  sometimes  slip  down.  Not  infrequently  I  have 
succeeded  in  bringing  down  the  foot  by  grasping  it  with  long  pressure 
or  vulsellum  forceps.  Of  course,  if  the  cervix  admits  two  or  more 
fingers,  there  is  no  great  difficulty  in  seizing  the  foot. 


882  OPERATIVE  MII>WII'Kl;Y 

At  one  time   I   employed    this  method   to   the   exclusion   of  the 

external,  but  in  recent  years  I  have  had  recourse  to  it  only  when 
external  version  has  failed.  On  many  occasion e  one  accomplishes 
as  much  by  purely  external  manipulations,  and  with  less  chance  of 
rupturing  the  membranes.  Naturally,  after  the  membrane-  have 
ruptured,  the  method  of  Braxton  Eicks  will  succeed  for  some  time 
after  external  version  is  impossible.  The  indications  for  the  opera- 
tion are  many,  but  placenta  pra  via  is  one  of  the  most  im- 
portant. Its  value  in  that  complication  is  fully  discussed  elsewhere  I 
(Chapter  XXXIII.). 


CHAPTER  XXIII 

FORCEPS 

A  treatise  on  practical  obstetrics  is  not  the  place  to  detail  the  history 
of  the  forceps.  It  is  quite  fitting,  however,  that  I  should  consider 
how  axis-traction  rods  came  to  be  added  to  the  instrument,  and  should 
attempt  to  estimate  the  value  of  this  last  modification. 

History  and  Mechanism  of  Axis-Traction  Forceps. 

Tarnier  will  ever  be  honoured  as  the  inventor  of   axis-traction 
forceps,  and  deservedly  so.     But  long  before  Tarnier  described  his 


Fig.  147. — Tamier's  Axis-Traction  Forceps. 

instrument  in  1877  (Fig.  147),  it  had  been  fully  appreciated  that, 
even  with  the  long  double-curved  forceps,  traction  in  the  axis  of  the 
pelvis  was  impossible,  and  that  a  great  deal  of  the  force  exerted  by 
the  operator  was  lost  by  the  head  being  pulled  against  the  anterior 

333 


384 


ol'KKATlVK   MIDWIFERY 


pelvic  wall.  Levret,  Smellie,  and  Baudelocque,  for  (••.ample,  in  order 
to  obviate  this,  gave  directions  how  traction  was  to  be  made  as  far 
back  as  possible. 

With  the  object  of  obtaining  traction  in  the  axis  of  the  pelvis, 
many  alterations  and  additions  to  the  ordinary  double-curved  forceps 
have  been  suggested.  One  of  the  earliest — that  of  Saxtorph  and 
his  pupil  Stein — was  bands  through  the  fenestra'  of  the  blades.  A 
century  later  this  suggestion  reappeared  in  the  recommendation  of 
Poullet  to  pass   cords    through    holes  made  immediately  below   the 


Flu.  148. — Pajot's  Manoeuvre. 

The  accoucheur  pulls  on  the  handles  of  the  forceps  with  his  right  hand,  while  with  his  left 

lie  [>ulls  on  the  shanks. 


fenestras      The  manoeuvre  commonly  known  as   Pajot's  (Fig.   1  18 
was  described  by  Osiander,  a  pupil  and  assistant  of  Stein,  although 
it  was  really  first  suggested  by  Saxtorph.     Until  quite  recently  it  was 
very  generally  employed,  and  is  still  made  use  of   by  some  of  the 
older  obstetricians. 

As  far  as  can  be  ascertained,  the  suggestion  of  having  special 
traction  handles  was  first  made  by  Hermann  of  Berne  in  1844 
(Fig.  149).  But,  as  Milne  Murray  very  rightly  pointed  out,  the 
rods  in  Hermann's  forceps  were  employed  on  the  same  principle  as 
Osiander  and   Pajot   effected   their  manoeuvres.      Hermann's  device 


FORCEPS 


335 


seems  to  have  been  forgotten,  if,  indeed,  it  ever  became  very  generally 
known. 

An  important  step  in  the  evolution  of  the  instrument  was  Hubert's 


Fig.  149. — Hermann's  Forceps. 

traction  bar,  described  in  1860,  for,  undoubtedly,  by  it  traction  could 
be  exerted  in  the  axis  of  the  pelvis.     Still  later,  curving  the  ends  of 


Fiu.  150. — Defects  of  Ordinary  Forceps      (Tarnier.) 

A,  E,  C,  Line  of  traction  ;  A,  D,  B,  ideal  line  of  traction,  and  very  nearly  obtained  in  the 
best  form  of  axis-traction  forceps  ;  A,  S,  F,  force  wasted  against  the  symphysis  pubis. 

the  handles,  and  a  detachable  traction  handle  applied  either  to  the 
upper  or  lower  ends  of  the  handles,  were  recommended,  and  some- 
times employed. 


886 


OPERATIVE  MIDWIFERY 


The  mechanics  ol   axis-traction   Forceps  was  very  carefully  con- 
sidered by  Tarnier1  and  Milne  Murray.8    To  those  interested  in  the 

Bubjecl  1  would  hcitrtily  commend 
the  writings  of  those  two  authorities. 
Here  I  will  only  say  a  word  or  two 
about  the  matter. 

It  is  perfectly  evident  to  every  one 
employing  the  ordinary  forceps,  with 
the  head  high  in  the  cavity,  that  a 
large  amount  of  force  is  lost  against 
the  anterior  pelvic  wall.  Tarnier 
(Fig.  150)  estimated  that  nearly  half 
the  traction  force  is  lost.  With  axis- 
traction  forceps  this  is  in  great  part 
saved.  Another  important  point,  de- 
monstrated by  Murray  more  espe- 
cially, was  that  the  ideal  attachment 
of  the  traction  rods  is  just  below  the 
fenestra;  of  the  blades  (Fig.  151  . 
Thus,  such  forms  as  Neville's 
(Fig.  152),  where  they  are  attached 
to  the  upper  part  of  the  handles,  and 
the  older  forms  in  which  there  is  a 
pelvic  curve  connected  with  the  lower 
end  of  the  handles,  although  better 
than  forceps  with  no  traction  rods,  are 
less  satisfactory  than  Tarnier's  and 
its  modifications. 

That  this  should  have  been  proved 
mathematically  is  very  interesting, 
for  it  agrees  with  the  practical  experi- 
ence of  my  colleagues  and  myself  in  the  Maternity  Hospital.  For 
several  years  I  used  exclusively  Neville's  forceps,  but  I  found  it  much 
less  efficient  than  such  forms  as  Murray's  and  Simpson's.  On  many 
occasions,  when  I  was  in  the  habit  of  employing  forceps  above  the 
brim,  I  failed  to  deliver  with  Neville's  forceps,  and  succeeded  with 
Murray's.  Of  all  varieties  of  axis-traction  forceps,  then,  Tarnier's 
and  the  various  modifications  of  it — Simpson's,  Murray's,  Culling- 
worth's,  and  Bonnet's,  etc. — are  the  best,  theoretically  and  practically. 
The  English  modifications  of  Tarnier's  forceps,  excepting  Bonnet's, 
have  the  traction  rods  attached  to   the  outside  of  the  blades.      In 

1  Trans.  Inter.  Med.  Congress,  London,  1881,  vol.  iv. 

2  Trans.  Edin.  Obst.  Soc,  vol.  xvi.,  etc. 


Fig.  151.  Mechanical  Construction  of 
Tarnier's  Forceps.     (Milne  Murray. 

X,  Centre  point  of  blade  tip  :  V,  junc- 
tion of  blade  and  shank  ;  X,  Y,  cord 
of  arc  of  blade;  E,  F,  bisects  cord 
at  right  angles;  <J,  X,  V,  Y,  II, 
circle  whose  centre  is  on  E,  F,  and 
of  which  X,  V,  Y  is  an  are;  A,  B, 
tangent  to  arc  at  V  :  Y,  theoretical 
position  for  attachment  of  traction 
rods  ;  Z,  best  practical  position  for 
ditto  :  X,  T,  traction  rods. 


FORCEPS  337 

Tarnier's  and  Bonnet's,  however,  the  rods  are  inserted  on  the  inside. 
The  advantage  claimed  for  the  latter  is  that  the  vulvar  orifice  is  not 
so  much  stretched. 

It  is  a  convenience  to  have  the  rods  detachable  (Fig.  153),  for 
after  one  has  become  familiar  with  the  forceps,  and  the  head  just 
requires  a  little   help   over    the   perineum,  the  instrument   can    be 


Fig.  152.— Neville's  Axis-Traction  Forceps. 


Fig.  153. — Milne  Murray's  Axis-Traction  Forceps  with  Detachable  Handles. 

applied  without  the  rods.     I  have  never  been  able  to  appreciate  the 
great  advantage  of  axis-traction  forceps  at  the  outlet. 

Some  years  ago  Murray,  recognizing  the  fact  that  the  pelvic  axis 
varies  in  different  individuals,  devised  a  form  of  forceps  in  which 
the  direction  of  traction  could  be  altered  to  suit  the  obliquity  of  the 
particular  pelvis.  He  described  it  as  an  adjustable  axis-traction 
forceps  (Fig.  154).  The  idea  was  without  doubt  sound  enough  in 
theory,  but  it  was  too  theoretical ;  the  instrument  was  cumbersome 


888 


OPERATE  i:  Mihwii  i:i;v 


and  troublesome  of  application,  so  that,  in  common  with  others,  we 
gave  up  employing  it  in  the  Glasgow  Maternity  Hospital. 

We  have,  then,  in  the  modern  a\is-lraction  forceps  an  in.-trument 
perfect  in  construction  as  far  as  our  present  knowledge  goes.  We 
must  not  forget,  however,  that  we  are  constantly  employing  it  in  a 
canal  whose  axis  and  capacity  varies,  and  to  a  body — the  foetal  head 
— whose  position,  size,  and  consistency  often  differ  from  the  normal. 
That  being  so,  it  behoves  us  ever  to  employ  forceps  with  care  and 
judgment,  and,  above  all,  never  to  forget  the  limitations  of  this 
wonderful  and  useful  instrument.  These  limitations  I  shall  refer 
to  later 

At  this  stage  some  may  ask,  Is  an  emphatic  pronouncement  in 
favour  of  axis-traction    forceps   justifiable?     Personally,   I  have    no 


Fig.  154.— Milne  Murray's  Axis-Traction  Forceps  with  Adjustable  Traction  Handle. 


hesitation  in  answering  in  the  affirmative,  although  many  obstet- 
ricians in  England,  America,  Germany,  and  France  question  this. 
All  are  agreed  that  in  theory  axis-traction  forceps  is  superior,  and 
nearly  every  one  admits  that  in  practice,  with  the  head  high  in 
the  pelvis,  delivery  is  easier.  Those  who  object  to  the  general 
employment  of  axis-traction  forceps  argue  that,  as  one  seldom  en- 
counters cases  requiring  the  instrument,  the  simple  double-curved' 
forceps  is  sufficient.  But  such  reasoning  is  unsound,  for  how  is  it 
possible  that  experience  sufficient  for  difficult  cases  can  he  gained 
unless  one  has  employed  and  become  perfectly  familiar  with  axis- 
traction  forceps  in  simple  cases  ?  From  my  own  experience  I  can 
with  all  truthfulness  that  with  a  little  practice  axis-traction  forceps  is 
just  as  easily  applied  as  the  ordinary  double-curved  instrument. 


FORCEPS  839 


Action  of  the  Forceps. 

Before  proceeding  farther,  we  must  consider  how  the  forceps 
acts.  Until  recently  it  was  the  custom  to  attribute  five  actions  to 
the  forceps :  (1)  Tractor ;  (2)  compressor ;  (3)  lever ;  (4)  rotator  ; 
(5)  stimulator  of  uterine  action. 

The  last — the  so-called  '  dynamic  '  action — is  often  observed  in 
cases  of  forceps  delivery  at  the  outlet.  Quite  recently  I  had  a  case 
where  the  head  had  been  delayed  several  hours  at  the  outlet  owin^ 
to  uterine  inertia.  I  had  no  sooner  introduced  one  blade  than  strong 
contractions  followed,  and  the  labour  was  completed  without  further 
interference.     But  one  never  relies  upon  this  action  in  practice. 

Then,  again,  few  make  much  use  of  forceps  as  a  '  rotator,'  say  in 
occipito-  or  mento-posterior  positions,  while  the  '  lever  '  action,  used 
to  any  extent,  is  unwise.  We  still  employ  a  slight  pendulum  move- 
ment occasionally,  but  never  to  the  extent  of  levering  down  first  one 
side  and  then  the  other.  There  remains,  therefore,  only  the  two 
actions,  '  traction  '  and  '  compression.' 

First  and  foremost,  the  forceps  is  a  tractor.  Applied  in  the 
proper  position  to  a  normal  head,  it  is  only  a  compressor  to  the 
extent  of  allowing  a  sufficiently  firm  grasp  of  the  head.  Barnes 1  says  : 
'  The  blades  are  held  in  close  apposition  to  the  head  by  the  soft  parts 
and  the  pelvis  of  the  mother.  ...  In  many  cases  this  outer  pressure 
upon  the  bows  of  the  blades  is  enough  to  serve  for  traction.'  But 
that,  of  course,  only  applies  if  traction  is  very  moderate,  and  if  little 
resistance  has  to  be  overcome. 

The  amount  of  traction  which  can  be  exerted  by  the  forceps, 
especially  the  axis-traction  forceps,  is  enormous.  I  have  seen 
accoucheurs  with  their  feet  up  against  the  couch,  applying  all  their 
strength.  I  have  occasionally  exerted  a  considerable  amount  of  force 
myself,  although  I  believe  this  is  seldom  justifiable.  The  instrument 
is  then,  as  a  rule,  being  used  badly  or  is  unsuitable,  and  some  other 
operation  should  be  substituted. 

The  cases  in  which  I  have  required  to  exert  most  force  have  been 
where  the  head  was  large,  and  the  occiput  was  posterior.  When  it  is 
simply  a  large  head,  without  any  malformation  or  malposition,  and 
there  is  no  pelvic  deformity,  traction  must  be  continued  until  delivery 
is  completed.  Theoretically,  if  the  head  is  of  unusual  size  and  great 
traction  is  required  to  effect  delivery,  symphysiotomy  should  be  per- 
formed. As  a  matter  of  fact,  in  practice,  however,  the  extreme  difficulty 
will  not  occur  if  the  head  is  given  plenty  of  time  to  mould,  the  forceps 

1  Op.  cit.,  p.  -23. 


:j40  OPERATIVE  MIMYIFKliY 

is  carefully  applied,  and  traction  is  made  in  the  axis  of  the  pelvis. 
The  same  applies  to  occipito-poaterior  positions — by  rotating  the  head 
extreme  traction  is  unnecessary. 

It  is  when  the  pelvis  is  deformed  that  the  great  danger  of  exerting 
too  much  force  arises.  In  such  cases,  if  one  or  two  strong  pulls  (with 
the  patient  in  the  "Walcher  position  should  the  pelvis  be  flat),  fail  to 
bring  the  head  past  the  brim,  no  further  attempts  should  be  made. 
A  head  which  has  been  allowed  to  mould,  and  which  does  not  come 
through  after  one  or  two  attempts,  should  be  extracted  after  pubi- 
otomy  or  craniotomy. 

As  regards  the  forceps  as  a  compressor  of  the  total  head,  I  have 
already  pointed  out  that  the  blades  applied  to  the  sides  of  an  ordinary - 
sized  head  compress  it  but  slightly.  That,  at  least,  is  true  of  the 
ordinary  double-curved  forceps,  but  when  one  takes  the  axis-traction 
forceps,  which  has  a  '  butterfly '  screw,  the  compression  is  very  much 
greater.  If  this  screw  is  tightened,  even  with  the  blades  applied 
exactly  over  the  sides  of  the  head,  compression  is  quite  decided. 
Much  greater  is  it,  of  course,  when  the  forceps  grasps  the  head  obliquely 
or  longitudinally,  as  it  must  do  when  it  is  employed  with  the  head 
lying  transversely  or  obliquely  at  the  brim. 

There  are  two  important  points  to  be  considered  here  :  The  first  is 
the  amount  of  safe  compression,  the  second  is  the  effect  compression 
in  one  diameter  has  upon  the  other  diameters  of  the  head.  Unfor- 
tunately, the  first  question  cannot  be  answered,  for  there  is  no  means 
of  measuring  the  compression  exerted  :  and,  again,  different  children 
bear  compression  differently.  Personally,  I  have  found  that,  with 
Murray's  forceps  applied  transversely  to  a  normally  sized  head,  and 
with  the  butterfly  screw  not  very  tightly  screwed  up  and  occasionally 
loosened,  a  forceps  delivery  which  takes  more  than  fifteen  to  twenty 
minutes  is  attended  with  decided  asphyxia.  Some  years  ago  I  was  in 
the  habit  of  keeping  the  forceps  on  and  taking  a  very  long  time  to  de- 
liver primiparre,  with  the  object  of  preserving  the  perineum  intact. 
In  thai  latter  respect  the  results  were  highly  satisfactory,  but  I  can 
remember  once  or  twice  losing  the  child.  Now  I  do  not  take  so  much 
time,  and  if  the  birth  has  been  very  protracted  I  remove  the  forceps 
when  the  head  is  passing  through  the  vulvar  orifice. 

Besides  continuity  of  compression,  the  amount  of  traction  exerted 
must  be  considered,  for  the  amount  of  compression  is  in  proportion  to 
the  amount  of  traction.  Barnes1  says  :  '  The  pressure  is  equal  to 
about  half  the  traction  ;  thus,  if  you  exert  a  traction  force  of  about 
50  pounds,  the  pressure  on  the  head  is  about  25  pounds.'  This 
amount  of  pressure  must  be  often  exceeded  if  Duncan's  conclusion  is 

i  Op.  <•//..  p.  27. 


FORCEPS  ill 

correct.1  '  We  may,  therefore,  I  think,  safely  venture  to  assert  as  a 
highly  probable  conclusion  that  the  great  majority  of  labours  are  com- 
pleted by  a  force  not  exceeding  40  pounds.' 

A  word  about  the  other  question — the  effect  compression  in  one 
diameter  has  upon  the  others.  The  earliest  experiments  are  those  of 
Baudelocque,  and  it  is  noteworthy  that  his  results  agree  in  great  part 
with  those  of  Budin  and  Murray  a  century  later.  Baudelocque2  made 
a  number  of  experiments  upon  dead  infants,  and,  amongst  other  con- 
clusions, he  came  to  the  following  :  '  Lastly,  that  the  diameter  which 
crosses  the  direction  in  which  we  compress  the  head,  far  from  aug- 
menting in  the  same  proportion  as  the  other  diminishes,  does  not 
usually  increase  a  quarter  of  a  line,  and  sometimes  decreases.'  This, 
of  course,  has  reference  to  the  effect  compression  in  the  antero- 
posterior direction  has  upon  the  transverse  diameter  of  the  head. 
What  Baudelocque  did  not  appreciate,  however,  was  that  the  vertical 
diameter  of  the  head  was  effected  by  compression. 

It  was  Budin,  and  later  Milne  Murray,3  who,  while  confirming 
Baudelocque's  conclusions,  pointed  out  that  antero-posterior  com- 
pression of  the  head  resulted  in  an  increase  in  the  vertical  diameter. 
In  a  few  experiments  which  I  carried  out  in  the  Maternity  Hospital 
I  came  to  exactly  the  conclusions  indicated  by  Budin  and  Milne 
Murray. 

Indications  for  Forceps. 

The  indications  for  interference  with  forceps  may  be  arranged  in 
the  following  groups  : 

1.  Faults  in  the  forces. 

2.  Faults  in  the  passage. 

3.  Faults  in  the  child. 

4.  Dangers  threatening  the  life  of  the  mother. 

5.  Dangers  threatening  the  life  of  the  child. 

Many  prefer  to  divide  the  indications  between  the  last  two  groups, 
and,  in  a  sense,  of  course,  these  embrace  the  others  ;  but  I  find  the 
more  extended  classification  allows  one  to  explain  better  when  forceps 
should  be  employed. 

Faults  in  the  Forces.— Once  a  patient  has  reached  the  second 
stage — the  application  of  forceps  before  cannot  be  considered — I  see 
no  object  in  allowing  labour  to  continue  indefinitely.     My  practice, 

1  '  Researches  in  Obstetrics,'  p.  819. 

2  'A  System  of  Midwifery,'  translated  by  Heath,  1790,  vol.  ii.,  p.  377. 

3  Edin.  Med.  Joum.,  1888,  vol.  xxxiv.,  part  i.,  p.  417. 


842  OI'KHATIVK  MIDWIFERY 

therefore,  is  to  terminate  labour  by  forceps  after  the  second  Btage  has 
lasted  four  hours,  even  although  both  maternal  and  foetal  pulses  are 
normal.  The  operation  is  perfectly  Bimple,  tor  the  head,  with  few 
exceptions,  has  already  reached  the  outlet.  Indeed,  if  it  has  not 
advanced  so  far,  one  should  suspect  the  existence  of  some  abnormality, 
such  as  malposition  of  the  head,  pelvic  deformity,  etc.,  which  has  I 
overlooked. 

Many  writers  maintain  that  simple  delay  is  no  reason  for  inter- 
fering, and  that  one  cannot  place  a  time  limit  upon  the  duration  of 
the  second  stage.  In  theory  that  may  be  sound  enough,  hut  it  is 
extremely  difficult  to  follow  out  in  domestic  practice.  The  early 
application  of  forceps  in  the  second  stage  merely  as  a  matter  of 
convenience  is  quite  unjustifiable,  for  undoubtedly,  if  the  child  is 
pulled  from  high  up  in  the  pelvis,  the  risks  of  lacerating  the  vagina 
and  perineum  are  greatly  increased.  But  the  other  extreme  of  waiting 
until  there  are  indications  in  the  maternal  and  foetal  pulses,  no  matter 
how  long  the  delay  in  the  second  stage  may  be,  is  also  unwise. 

In  Winckel's  large  treatise1  Wyder  discusses  this  matter,  and 
favours  delay  until  indications  of  disturbances  in  mother  or  child 
arise.  Olshausen  and  Yeit,'2  however,  place  less  restriction  upon  the 
use  of  the  instrument  in  cases  of  enfeeblement  of  the  forces.  The 
general  opinion  of  English  operators  is  that  given  by  Herman,"  who, 
while  opposed  to  early  interference  in  uterine  inertia,  thinks  it  unwise 
to  delay  indefinitely  the  employment  of  forceps. 

Before  leaving  the  subject  of  uterine  inertia  as  an  indication,  let 
me  again  emphasize  the  importance  of  making  sure  that  this  really  is 
the  cause  of  the  delay,  as  it  rarely  is  the  true  cause,  if  the  head 
is  arrested  high  in  the  pelvic  cavity. 

Faults  in  the  Passage. — Cases  of  this  group  test  most  the 
judgment  of  the  accoucheur.  The  forceps,  especially  the  axis-traction 
forceps,  is  an  instrument  of  enormous  power.  By  means  of  it  one  can 
overcome  great  obstruction  in  the  parturient  canal,  but  there  is  a  limit 
to  the  traction  force  which  should  be  exercised.  The  power  which  can 
be  exerted  with  one's  forearms  is  a  fair  measure  of  the  force  which  may 
be  safely  employed.  For  the  operator  to  place  his  feet  against  the 
bed  and  exert  all  his  strength  is  not  obstetrics.  It  means  that  he  is 
operating  unskilfully,  or  that  he  has  chosen  the  wrong  operation.  I 
cannot  too  strongly  discourage  this  employment  of  extreme  force,  a 
procedure  far  too  general  in  this  country. 

As  regards  the  vagina,  obstruction  is  uncommon  except  at  the 
lower  part.     Malformations,  cicatrices,  tumours,  etc.,  are  occasionally 

1  lid.  iii.,  Theil  i.,  p.  497.  "  '  Lehrbuch  der  Geburtshiilfc'  Auf.  v.,  1902. 

3  '  Difficult  Labour,'  1910,  p.  389. 


FORCEPS  348 

encountered;  but  they  are  very  rare,  and  if  they  are  of  sufficient 
extent  to  cause  a  decided  obstruction  it  is  never  justifiable  to 
deliver  by  simple  traction.  Incisions  and,  if  these  are  not  sufficient 
to  allow  of  the  ready  passage  of  the  child,  removal  of  the  tumour 
or  Cesarean  section  are  the  methods  of  delivery  which  should  be 
employed. 

At  the  perineum  there  is  sometimes  slight  difficulty,  especially 
with  muscular  women,  who,  it  has  often  been  remarked,  have  not  the 
easiest  labours.  But,  apart  altogether  from  muscularity,  certain 
individuals  have  peculiarly  rigid  tissues  —  elderly  primiparae,  for 
example.  I  have  sometimes  seen  it  well  marked,  however,  in  quite 
young  primiparae. 

When  uterine  contractions  are  strong  and  regular,  spasmodic 
rigidity  of  the  muscles  of  the  pelvic  floor  may  be  removed  by  anaes- 
thesia. Short  of  this,  a  full  dose  of  opium  is  often  sufficient.  If  the 
forces  are  still  unable  to  expel  the  head  unaided,  forceps  must  be 
applied.  In  cases  where  the  pelvic  floor  does  not  relax  under  anaes- 
thesia, it  is  often  necessary  to  exert  a  considerable  amount  of  force 
with  the  instrument.  Extensive  laceration  of  the  perineum  will  then 
frequently  result,  so  that  it  is  advisable  in  such  cases  to  incise  the 
vulvar  orifice  (Episiotomy,  p.  649). 

But  the  most  troublesome  cases  of  forceps  delivery  are  when 
the  bony  pelvis  is  at  fault — not  only  because  considerable  manual 
dexterity  is  necessary,  but  because  great  judgment  is  required  in 
deciding  when  the  pelvic  deformity  is  too  great  for  forceps.  This 
matter,  however,  is  of  such  extreme  importance  that  I  have  considered 
it  in  a  separate  chapter. 

Faults  on  the  Side  of  the  Child.  —  Amongst  the  foetal  ab- 
normalities which  may  call  for  forceps  may  be  mentioned  large 
size  of  the  head  (except  malformations  such  as  hydrocephalus), 
malpresentations  such  as  occipito-posterior  presentations  or  facial 
presentations,  and  difficulty  with  the  after-coming  head  in  breech 
presentations. 

Dangers  threatening"  the  Life  of  the  Mother. — In  this  group 
come  to  be  mentioned  such  conditions  as  eclampsia,  dj^spnoea  from 
heart  disease,  advanced  phthisis,  or  any  condition  in  which,  after  the 
os  is  fully  dilated,  rapid  delivery  is  deemed  necessary.  But  short 
of  these  serious  conditions  forceps  is  indicated  if  the  maternal 
temperature  and  pulse  begin  to  rise  in  the  second  stage,  if  the  patient 
becomes  restless,  if  the  vagina  becomes  dry  and  hot,  but  only  occa- 
sionally and  with  great  care  if  BandVs  ring  is  distinct. 

Dangers  threatening  the  Life  of  the  Child. — Some  children  are 
more  affected  by  a  labour  than  others.     One  must,  therefore,  auscul- 


344  OPERATIVE  Mll»\Viri:i;V 

tate  the  foetal  hear!  from  time  to  time  if  there  la  any  delay  in  the 
second  Btage,  and  even  in  the  tirst  Btage  if  the  membranes  have 
ruptured  prematurely.     The  normal  foetal  hearl  rate  is  about  180.     A 

progressive  decrease  in  pulse-rate  indicates  danger,  and  if  it  falls  to 
100  or  lower  no  time  should  be  lost  in  delivering  the  child.  Even 
more  serious  than  simple  slowing  is  irregularity.  Increased  rapidity 
usually  precedes  slowing,  although  not  necessarily.  One  must 
remember  that  during  a  uterine  contraction  the  foetal  heart-b< 
become  slower,  but  they  should  return  to  the  normal  again  immedi- 
ately after  the  contraction  passes  off.  If  they  do  not  do  so,  then  the 
child  is  in  danger,  and  should  be  extracted  as  soon  as  possible. 

When  one  waits  for  distinct  indications  on  the  pari  of  the  foztua 
before  applying  forceps,  the  extraction  must  not  be  too  prolonged,  for  the 
circulation  of  the  foetus  is  already  embarrassed.  With  this  rapid 
extraction  one  must  risk  rupturing  the  perineum,  or  a  vaginal  incision 
must  be  made. 

Conditions  which  must  be  Fulfilled  if  Forceps  are  to  be 

Applied. 

Before  one  proceeds  to  apply  forceps,  the  following  conditions 
must  be  fulfilled :  (a)  the  os  must  be  fully  dilated ;  (/;)  the  mem- 
branes must  be  ruptured ;  (c)  the  presentation  must  be  a  suitable 
one;  (<l)  there  must  not  be  too  great  disproportion  between  the  head 
and  the  pelvis ;  (e)  the  head  must  be  engaged. 

(a)  The  Os  must  be  Fully  Dilated. — It  is  very  questionable  if 
the  application  of  forceps  before  the  os  is  fully  dilated  is  ever  justifi- 
able. Even  when  it  is  of  the  greatest  importance  to  effect  speedy 
delivery,  it  is  generally  better  to  incise  the  cervix,  for  the  tears  pro- 
duced by  dragging  a  head  through  an  undilated  os  are  ragged  and 
may  be  very  extensive  and,  what  is  still  more  important,  cause  great 
shock  to  the  patient.  I  have  tried  once  or  twice  to  gently  drag  a  child 
through  an  imperfectly  dilated  os,  but  I  have  generally  lacerated  the 
cervix.  The  reason  for  this  is  that  the  cervix,  if  not  fully  dilated,  con- 
tracts whenever  one  pulls  on  the  child's  head.  Therefore,  I  always 
incise  the  cervix  if  I  wish  to  deliver  with  all  speed. 

There  is  no  doubt  that  the  untimely  application  of  forceps  is 
responsible  for  a  large  number  of  the  cases  of  laceration  of  the  cervix 
and  its  resulting  evils;  I  say  a  large  number  of  the  lacerations,  for, 
undoubtedly,  extensive  laceration  may  sometimes  occur  after  spon- 
taneous delivery. 

In  contracted  pelvis  the  expansion  of  the  cervix  often  appears  to 
be  arrested  short  of  complete  dilatation,  owing  to  the  bony  canal  pre- 


FORCEPS  345 

venting  descent  of  the  head,  and  so  it  is  a  little  difficult  to  say  when 
the  os  is  fully  dilated.  In  such  cases  the  cervix  is  soft  and  relaxed, 
and  gives  the  impression  that  it  will  offer  no  resistance  to  the  passage 
of  the  head.  Later,  of  course,  a  secondary  narrowing  may  occur, 
from  the  lips  of  the  cervical  canal  becoming  (edematous  owing  to 
long-continued  pressure.  Interference  should  anticipate  such  au 
occurrence. 

(/;)  The  Membranes  must  be  Ruptured.— I  do  not  for  a  moment 
believe  that  any  great  disaster  would  follow  the  application  of  forceps 
over  unruptured  membranes,  for  I  can  hardly  think  that  dragging  on 
the  membranes,  could,  as  is  stated,  cause  separation  of  the  placenta. 
Be  that  as  it  may,  however,  the  membranes  should  be  ruptured  before 
forceps  are  applied. 

(c)  The  Presentation  must  be  a  Suitable  One. — A  word  only 
is  necessary  with  regard  to  this  condition,  for  the  subject  has  been 
fully  discussed  elsewhere.  The  forceps  may  be  employed  in  all 
vertex  and  face  presentations,  but  not  in  brow  presentations.  For 
delivering  the  after-coming  head  forceps  are  also  very  useful 
(Chapter  V.). 

(d)  There  must  not  be  Too  Great  Disproportion  between  the 
Foetal  Head  and  the  Parturient  Canal. — That  is  to  say,  the  fcetal 
head  must  not  be  too  large,  as  in  cases  of  hydrocephalus,  nor  the 
parturient  canal  too  narrow,  as  in  cases  of  decided  bony  deformity. 
The  test  of  this  is  a  careful  bimanual  examination  of  head  and  pelvis. 
That  has  been  fully  detailed  and  considered  (Chapter  XII.) • 

(e)  The  Head  must  be  Engaged. — In  most  respects  this  condition 
is  embraced  by  the  previous  one.  Forceps  is  absolutely  unjustifiable 
in  contracted  pelvis  if  the  head  is  still  movable.  Occasionally  I  have 
employed  the  instrument  with  the  head  movable  at  the  brim  when 
immediate  delivery  was  urgent,  as  in  cases  of  heart  disease  or 
eclampsia,  but  only  when  the  pelvis  was  normal. 

Preparation  of  Patient   and  Method  of  applying'  the 

Forceps. 

Prior  to  the  application  of  forceps  it  is  of  the  greatest  importance 
that  the  patient  should  be  carefully  prepared  for  the  operation. 
Especially  must  every  precaution  be  taken  to  prevent  the  possibility  of 
any  septic  infection  occurring.  The  hands  of  the  operator  and  his 
instrument  must  be  sterilized,  and  the  vagina,  vulva,  and  surrounding- 
parts  of  the  patient  thoroughly  cleansed.  The  manner  of  carrying 
out  these  steps  has  been  fully  described. 

Next  to  care  in  preventing  septic  infection,  a  thorough  evacuation 


346  OPERATIVE  MI1>\\  II  l'.l;V 

of  the  bladder  is  of  the  greatest  importance.  I  am  perfectly  certain 
that  many  of  the  cases  of  partial  incontinence  following  parturition — 
cases  by  no  means  uncommon — are  the  result  of  pulling  the  child  out 
of  the  vagina  with  the  bladder  still  containing  a  considerable  quantity 
of  urine.  The  bladder  should  be  emptied  hy  catheter  just  In -fore  the 
introduction  of  the  blades,  for  only  hy  that  means  can  one  be  perfectly 
sure  that  it  is  thoroughly  evacuated.  This  is  an  easy  matter,  except 
in  those  cases  where  the  head  is  low  in  the  vagina  and  actually  press- 
ing upon  the  urethra.  In  the  latter  the  head  must  he  pushed  up  a 
little  way  to  allow  the  catheter  to  pass. 

The  emptying  of  the  howel  is  also  necessary,  not  only  hecause  it  is 
extremely  disagreeable  to  the  operator  to  have  fa-ces  escaping  while  he 
is  delivering  the  child,  but  because  their  escape  while  vaginal  manipula- 
tions are  being  carried  out  is  an  actual  danger  to  the  parturient. 

It  is  also  desirable  to  have  the  patient  under  an  anesthetic.  In 
the  case  of  a  primipara,  at  the  time  the  head  is  escaping  surgical 
anaesthesia  is  an  advantage,  for  a  patient  half  under  struggles  and 
tosses  about  so  much  that  it  is  very  difficult  to  control  her  and  prevent 
perineal  rupture. 

In  this  country  the  common  position  for  the  patient  to  assume  is 
the  left  lateral.  In  simple  forceps  delivery  I  employ  this  decubitus. 
It  is,  however,  advisable  that  the  accoucheur  should  also  accustom 
himself  to  operate  with  the  patient  on  her  back,  the  position  preferred 
in  all  other  countries  except  Great  Britain.  It  is  largely  a  matter  of 
custom  which  position  is  chosen  in  the  simpler  cases  of  forceps 
delivery  ;  but  when  the  instrument  has  to  be  applied  with  the  head 
at  the  brim,  and  especially  with  the  pelvis  deformed,  the  dorsal 
decubitus  is  better,  not  because  the  operation  is  easier  in  that  position, 
but  because  the  blades  can  be  applied  more  exactly,  and  the  head  does 
not  slip  out  of  the  pelvis.  Besides,  in  contracted  pelvis  it  is  often  an 
advantage  to  drop  the  legs,  and  put  the  patient  in  what  is  known  as 
the  Walcher  or  '  hanging-leg  '  position  (Fig.  171).  A  very  exhaustive 
discussion  regarding  the  value  of  this  position  took  place  at  the  Inter- 
national Congress  in  Amsterdam  in  1899.1  It  was  generally  admitted 
by  all,  with  the  exception  of  Bar,  that  an  increase  of  about  1  centi- 
metre (0*4  inch)  resulted.  Those  interested  in  the  subject  will  find  it 
fully  considered  by  Fothergill.- 

In  the  Walcher  position  the  weight  of  the  hanging  legs  depresses 
the  fore-part  of  the  pelvis,  when  there  of  necessity  results  an  increase 
in  the  conjugata  vera.  The  conjugate  at  the  outlet  is  diminished, 
however  ;  consequently,  after  the  head  has  passed  the  brim  the  position 

1  Zent.  f.  Gijn.,  No.  35,  1899. 

-  Brit.  Mr,/.  Jnuni..  1896,  vol.  ii.,  p.  1290. 


F011CEPS 


:;i 


should  be  changed  to  the  lithotomy  one-  Apart  altogether  from  actual 
measurements  made  on  the  cadaver,  practical  experience  confirms  the 
advantage  of  the  position.  Upon  several  occasions  I  have  delivered 
with  forceps  in  the  Walcher  position  after  failing  in  the  lateral  or 
dorsal.  My  colleagues  in  the  Maternity  Hospital  have  had  similar 
experiences. 

There  is  another  distinct  advantage  which  the  dorsal  decubitus 
possesses  in  cases  of  '  high  forceps.'  If  a  patient  deeply  anesthetized 
is  rolled  round  on  her  side,  the  head,  although  well  engaged,  slips  out 
of  the  brim,  because  the  body  of  the  child  falls  over  to  the  more 
dependent  side.  The  operator  has,  therefore,  to  apply  the  instrument 
to  a  movable  head,  and  may  pull  it  into  a  position  other  than  that  in 
which  it  was  moulding  and  trying  to  pass. 


Fig.  155. — The  Ideal  Position  of  the  Blades  with  respect  to  the  Foetal  Head. 


We  must  now  consider  an  important  question — the  relationship 
of  the  blades  to  the  maternal  pelvis  and  foetal  head.  Should  the 
blades  be  applied  relatively  to  the  pelvis  or  relatively  to  the  foetal 
head? 

The  blades  of  any  of  the  ordinary  varieties  of  forceps  are  so 
constructed  that  they  are  in  perfect  position  when  they  grasp  the 
head  transversely  (Fig.  155)  and  are  placed  transversely  in  the 
pelvis  (Fig.  15G).  If  the  head  of  the  child  always  lay  in  the  pelvis, 
with  its  antero-posterior  diameter  in  the  antero-posterior  diameter  of 
the  pelvis,  this  would  be  readily  secured  ;  but  the  long  or  antero- 
posterior diameter  of  the  head  does  not  always  occupy  the  conjugate — 
indeed,  only  at  the  lower  part  of  the  cavity  does  it  do  so.  At  the  brim 
it  is  in  the  oblique  or  transverse  diameter  of  the  pelvis ;  consequently, 
in  such  cases  the  blades  cannot  grasp  the  head  transversely  and  lie 
transversely  in  the  pelvis. 


848 


OPERATIVE  MIDWIFERY 


If  one  applies  the  forceps  to  a  dried  pelvis  it  ifl  at  once  evident 
that  each  blade  has  a  certain  range  of  what  may  be  called  'safe 
movement/  and  that  the  limits  of  this  are  the  ilio-pectineal  eminence 
and  the  sacro-iliac  synchondrosis  on  each  side  (Fig.  L57).     With  the 

head   lying  in  the  Oblique  diameter,  therefore,  it  is  still  possible  to 

a  transverse  grasp  by  applying   one   blade  over  these  two  points. 
Hence  the  old  rule  in  such  cases:   'Apply  the  blades  in  the  oppoe 
oblique   diameter  to  that  in  which  the  head  lies.*     When,  however, 
the  long  axis  of  the  head  occupies  the  transverse  diameter  of  the 
brim,  as  in  flat  pelvis,  it  is  obviously  impossible  to  apply  the  blades 


Fis.  156.— The  Ideal  Position  of  the  Blades  relatively  to  the  Maternal  Pelvis.     (I'mmni.) 


transversely  to  the  head,  unless,  of  course,  one  moves  them  beyond 
the  ilio-pectineal  eminence  and  the  sacro-iliac  synchondrosis,  and 
places  them  in  the  conjugate  diameter  of  the  pelvis.  I  shall  refer  to 
such  cases  when  speaking  of  contracted  pelvis. 

In  advocating  a  deliberate  grasping  of  the  child's  head  and  the 
placing  of  the  blades  against  the  head,  I  am  simply  returning  to  the 
teaching  of  the  older  obstetricians,  Levret,  Smellie,  and  Baudelocque. 
Pushing  in  the  blades  to  the  side  of  the  pelvis  and  trusting  to  the 
grasp  being  satisfactory  is  of  quite  recent  date,  and  although  it  is  very 
generally  followed,  and  is  the  method  of  application  recommended  by 
such  writers  as  Barnes,  Galabin,  and  Playfair,  I  have  always  taken 


FORCEPS 


349 


exception  to  it.1  I  need  only  mention  the  cases  where,  by  applying 
the  blades  in  the  casual  way  mentioned,  the  instrument  repeatedly 
slips  off  the  head,  until  finally  a  satisfactory  grasp  is  obtained.  Would 
such  a  satisfactory  grasp  not  be  more  likely  to  be  obtained  if  the  blades 
from  the  first  were  applied  deliberately  to  the  child's  head  in  the 
direction  deemed  best  ?  I  am  not  alone  in  advocating  a  more  careful 
and  deliberate  grasp  of  the  head ;  some  of  the  most  distinguished 
obstetricians  of  the  present  day — as,  for  example,  the  late  Milne 
Murray,  Clarence  Webster,  Whitridge  Williams,  Pinard,  the  late 
Varnier,  and  Nagel — do  so. 


Fir;.  157. — Showing  the  Range  of  Safe  Movement  of  the  Blades  relatively  to  the  Pelvis. 

(Bumni.) 


We  have  now  reached  the  stage  when  I  may  describe  how  the 
forceps  are  to  be  applied,  and  in  so  doing  I  shall  first  take  a  simple 
case  where  the  head  is  low  down  in  the  pelvis,  and  afterwards  consider 
the  more  difficult  and  complicated  cases  in  detail. 

With  the  woman  in  the  left  lateral  position,  I  believe  it  best  to 
use  the  left  hand  internally  for  guiding  both  blades,  and  the  right  for 
holding  and  introducing  them.  When,  however,  the  dorsal  decubitus 
is  employed,  each  blade  is  best  guided  into  position  by  the  hand 
which  most  naturally  applies  itself  to  the  side  of  the  maternal  pelvis ; 

1  Lancet,  September  24,  1898. 


850 


OPERATIVE  MIDWIFERY 


thus,  (or  the  right  blade  the  operator's  left  hand  is  b<  -;.  and  for  the 
left  his  right. 

Having  determined  the  exact  relationship  of  the  long  axis  of  the 
head  to  the  bony  pelvis,  the  left  blade  is  introduced  by  passing  it  o 
the  fingers  of  the  left  hand,  which  is  in  the  vagina  (Fig.  L58  . 
blade  must  be  kept  closely  applied  to  the  Bide  of  the  total  head,  and 
carefully   guided   inside   the   os   externum.     Having   done   this,  the 
handle  is  depressed  and  carried  well  hack.      This   has   the  effec 
bringing  the  blade  over  the  most  suitable  part  of  the  child's  head.     It 


Fig.  158. — The  Application  of  tlie  Lower  or  Left  Blade. 
The  blade  and  traction  rod  are  held  as  indi 


also  takes  the  blade  out  of  the  operator's  way,  especially  if  there  is 
an  assistant  available  to  steady  it.  It  is  evident  from  the  illustration 
that  the  traction  rod  is  not  the  least  in  the  way,  being  held  along  with 
the  handle  by  the  right  hand. 

The  second  blade  may  be  introduced  as  was  the  first,  only  above 
and  to  the  right  side  of  the  pelvis,  opposite  to  the  other.  But  thai 
method  is  not  nearly  so  satisfactory  as  the  one  generally  employed 
Fig.  159).  In  the  latter  the  blade  is  passed  first  into  the  hollow  of 
the  sacrum,  and  is  then  rotated  into  position  opposite  the  first.  Some 
operators  introduce  the  first  blade  in  this  way  also.     The  operator 


FORCEPS 


351 


holds  it  with  the  traction  handle  well  out  of  the  way  and  resting  on 
the  dorsum  of  his  hand.  By  neglecting  this  little  precaution  all  the 
trouble  with  the  axis-traction  forceps  arises.  He  grasps  then  the 
handle  with  the  traction  rod  resting  on  the  dorsum  of  his  hand,  and 
under  the  guidance  of  his  other  hand  he  slips  the  blade  into  the 
hollow  of  the  sacrum.  Having  placed  it  over  the  forehead  of  the 
child,  he  rotates  it  round  into  the  position  desired,  opposite  the  first 
(Fig.  160),  and  he  finds  that  without  any  difficulty  the  blades  lock 
(Fig.  1(31).  Difficulties  with  locking  hardly  ever  occur  when  the  head 
is  low  down.     If  by  any  chance  they  should,  a  little  gentle  manoeuvring 


Fig.  159.—  The  Introduction  of  the  Upper  or  Right  Blade. 

The  lower  or  left  blade  is  held  well  back  while  the  right  or  upper  is  carried  into  the  hollow 
of  the  sacrum.  The  traction  rod,  it  will  be  observed,  is  not  in  the  way;  it  rests  on 
the  dorsum  of  the  operator's  right  hand. 

or  reintroducing  the  blades  will  right  the  matter.  The  instrument 
being  locked,  he  then  brings  the  traction  rod  of  the  right  blade,  which 
until  now  has  been  in  front,  into  position  alongside  of  its  fellow  by 
pushing  it  back  over  the  shank  of  the  blade.  The  butterfly  screw 
is  then  tightened,  and  the  traction  handle  attached  to  the  bars 
(Fig.  162).  As  I  have  said  before,  the  butterfly  screw  must  be  slackened 
from  time  to  time,  as  a  continuous  pressure  endangers  the  child. 

One  knows  when  a  good  grasp  has  been  obtained  by  the  blades 
of  the  forceps  being  applied  to  the  head  in  the  manner  already 
illustrated  (Fig.  155).  Bat  if  the  operator  has  not  troubled  about  how 
they  lie  relatively  to  the  head — as  is  unfortunately  the  custom  with 
so  many — it  will  be  evidenced  by  the  blades  locking  readily,  and  by 


852 


OPERATIVE  MII>\Vll'i:i;Y 


there  being  very  little  separation  between  the  ends  of  the  handles. 
In  high  forceps,  with  the  head  in  the  transverse  or  oblique  diameter, 
separation  of  the  handles  is  unavoidable;  but  with  the  head  low 
down  it  always  means  that  the  forceps  is  wrongly  applied,  or  that 
the  child's  head  is  lying  in  a  different  position  than  was  supposed. 
If  the  handles  are  widely  separated,  the  blades  should  be  removed, 
and  a  careful  examination  of  the  position  and  attitude  of  the  head 
again  made  before  they  are  reapplied. 

In  delivering  with  forceps,  one  should  do  so  with  the  expenditure 
of  the  minimum  of  force,  and  to  accomplish  this  one  should  always 


Fig.  160.—  The  Rotation  of  tin-  Right  or  Upper  Blade  from  the  Hollow  of  the  Sacrum  mi  to 
the  Pari  of  the  Child's  Head  desired. 

Observe  the  traction  rod  is  not  causing  the  operator  any  inconveniena  ■ 


try  to  pull  the  head  in  the  direction  it  would  be  driven  naturally.  In 
a  normal  delivery  the  occiput  is  pushed  lower  and  lower  down,  and 
slowly  rounds  the  symphysis  pubis.  The  occiput  does  not  become 
arrested  at  the  symphysis  pubis,  and  if  it  does,  premature  extension 
of  the  head  occurs,  with  the  result  that  a  larger  circumference  of  the 
head  is  brought  across  the  vulvar  orifice,  and  rupture  of  the  perineum 
follows.  Now,  with  forceps,  especially  the  ordinary  variety,  such  a 
mistake  is  very  liable  to  occur  if  traction  is  directed  too  soon  forwards. 
With  axis-traction  forceps  this  is  not  so  likely  if  one  allows  the 
handles  to  guide  one  as  to  the  direction  in  which  to  pull.    The  traction 


FORCEPS 


:;:,:; 


rods  should  be  kept  close  to  the  handles  as  the  latter  come  farther 
and  farther  forwards  (Fig.  168).  They  must  not  actually  touch  the 
handles,  otherwise  they  might  press  them  forwards.  In  such  a  way 
the  head  is  slowly  guided  over  the  perineum  (Fig.  1(54).  Traction, 
however,  must  not  be  continuous,  but  must  be  exerted  during  the 
uterine  contractions,  or,  if  they  are  very  infrequent,  at  regular 
intervals. 

I  have  sometimes  found  that  the  head,  if  small,  moves  within  the 
blades,  and  when  one  pulls  upon  the  forceps,  the  handles  pass  at  once 


Fir;.  161. 

The  Mades  are  now  locked.     The  traction  rod  of  the  right  blade  is  still  in  front, 
carried  back  over  the  shanks  beside  the  left  one. 


It  is  now 


forwards.  In  such  cases,  were  one  to  follow  the  handles,  traction 
would  be  made  too  soon  forwards,  with  the  result  that  the  occipito- 
frontal circumference  would  be  brought  through  the  vulvar  orifice 
and  the  perineum  ruptured.  The  best  course  in  such  a  condition  is 
to  help  the  occiput  down  with  one's  fingers,  or  retard  the  forehead  by 
pressing  it  from  behind. 

In  most  cases  I  do  not  remove  the  blades  before  the  head  escapes. 
The  advantage  of  leaving  the  blades  on  while  the  head  is  escaping  is 
that  by  means  of  them  the  too  rapid  birth  of  the  head  can  be 
controlled.  The  only  objection  to  keeping  them  applied — the  amount 
of  room  they  take  up  may  be  neglected — is  that,  if  the  head  is  im- 
perfectly grasped,  or  if  it  slips  within  the  forceps,  a  longer  diameter 
than  the  suboccipito-frontal  is  thrown  across  the  vulvar  orifice. 

23 


::;,1 


OPERATIVE  MIDWIFERY 


The   Edinburgh  school  attach   great  importance  to  keeping   the 
blades  on  when  extracting  a  child,  and  their  teachers  have  frequently  "i 
referred  to  the  advantages  of  axis-traction  forceps  in  preserving  the  I 
perineum  from  rupture.     Glasgow  and  other   British  schools  do  no< 
attach  so  much  importance  to  this. 

If  delivery  is  completed  without  the  blades,  the  head  must  never 
be  pushed  out  with  the  hands,  unless  the  occiput  is  prevented  from 
catching  on  the  symphysis.     Also,  the  mistake  must  not  be  made  of  J 
taking  the  blades  off  too  soon,  and  so  allowing  the  head  to  slip  back. 


Fig.  162, 

The  blades  are  locked  and  the  traction  rods  are  in  position.     The  blades  are  slightly 
gaping,  and  the  butterfly  screw  is  not  more  than  just  biting. 

Details  regarding  the  management  of  the  escape  of  the  head  and 
the  preservation  of  the  perineum  will  be  found  in  the  chapter  on 
Perineal  Rupture.  During  the  extraction  the  nurse  should  hold  up 
the  woman's  right  leg.  As  can  be  seen  from  the  illustration  (Fig.  164), 
the  leg  is  maintained  extended,  so  as  to  relax  the  perineum  to  the 
greatest  possible  extent. 


The  Head  High  in  the  Cavity,  but  lying*  in  the  Oblique 

Diameter. 

When  forceps  have  to  be  employed  with  the  head  high  in   the 
pelvic  cavity,  without  doubt  there  is  something  to  be  said  in  favour 


FORCEPS 


355 


of  placing  the  patient  in  the  lithotomy  position.  As  I  have  already 
mentioned,  in  that  position  the  blades  can  be  more  exactly  applied 
to  the  head,  if  necessary,  the  Walcher  or  hanging-leg  position  can 
be  made  use  of,  and  the  weight  of  the  trunk  maintains  the  child's 
head  fixed  in  the  pelvic  brim.  Barnes  says  :  '  Placing  the  woman  in 
the  dorsal  position  facilitates  extraction.' 

In  order  that  the  head,  situated  high  in  the  pelvis,  may  be  grasped 
laterally,  the  blades  must  lie  in  the  opposite  oblique  diameter  to  that 
occupied  by  the  long  axis  of  the  head  (Fig.  157).     To  accomplish  this 


Fig.  163. — Traction  Downwards  and  Backwards. 

The  traction  rods  are  all  but  touching  the  handles,  which  guide  one  as  to  the  direction 
in  which  traction  should  be  made. 


;he  blades  must  be  carefully  placed  over  the  sides  of  the  head,  not 
ust  casually  pushed  in  at  the  sides  of  the  pelvis. 

With  the  patient  in  the  lateral  position  one  proceeds  as  follows  :  An 
issistant  steadies  the  child  by  pressing  upon  the  fundus  uteri.  The 
)perator  then  passes  his  left  hand  into  the  vagina  and  determines  the 
3xact  position  of  the  head.  The  fingers  here  must  be  placed  well 
nside  the  margin  of  the  cervix,  and  the  blades  carefully  guided  through 
■he  os.  The  left  or  under  blade  is  passed  either  directly  up  towards 
.he  sacro-iliac  synchondrosis,  or  carried  into  the  hollow  of  the  sacrum 
md  rotated  on  to  the  side  of  the  child's  head.  It  is  then  held  in 
position  by  an  assistant.  The  second,  upper,  or  right  blade  is  best 
ntroduced  if  passed  into  the  hollow  of  the  sacrum  and  rotated  into 


856 


OPERATIVE   MIDWII'KIIV 


position.    One  must  make  sure  that  it  is  carried  well  forward  opposii 
the  ilio-pectineal  eminence.     The  handles  are  then  locked,  sometimei] 
with  a  little  difficulty,  bat  usually  fairly  easily,  if  tho  first  is  heh 
in   position  and   hoth    are    pressed   well    back.      If    the  difficulty  iij 
extreme,  it  is  advisable  to  remove  the  blades  and  reintroduce  them 
The  traction  bars  are  applied  as  already  described. 

I  must  admit  that  in  the  'high  operation'  the  traction  rod.-  an 
sometimes  a  little  trouble,  but  if  the  rule  I  have  laid  down  is  followed 
of  keeping  the  rod  of  the  right  or  upper  blade  well  forwards  until  th( 


Fir;.    Hil. 

The  head  is  being  extracted.     The  traction  rods  follow  tin-  handles  as  the  latter  pass 
forwards  and  upwards  between  the  parturient's  thighs. 

blades  are  locked,  a  very  little  practice  will  render  the  manipulations 
easy. 

Before  proceeding  to  traction  it  is  a  wise  precaution  to  make  surf 
that  the  cervix  is  quite  free,  and  that  the  blades  are  in  the  position 
desired.  One  or  two  tentative  efforts  at  traction  having  then  been 
made,  the  delivery  should  be  proceeded  with. 

Traction  must  be  in  the  right  direction — viz.,  in  the  axis  of  the 
pelvis.  As  T  have  already  described,  the  handles,  as  the  head  descends, 
are  one's  guide.  Traction  must  also  be  made  during  the  uterine  con- 
tractions, or,  if  they  are  absent,  at  short  intervals. 


FORCEPS  357 

If  the  patient  is  a  primipara,  some  time  will  be  required  to  bring 
the  head  down  through  the  whole  length  of  the  canal.  This  may  have 
an  injurious  effect  on  the  child,  especially  if  the  mistake  is  made  of 
keeping  the  butterfly  screw  tight. 

Occasionally  I  have  found  it  advisable  to  remove  the  blades  at  the 
outlet  and  reapply  them,  for  although  theoretically  delivery  may  be 
completed  with  the  grasp  first  obtained,  in  practice,  when  the  head 
reaches  the  floor,  a  better  grasp  may  often  be  secured  by  removing 
and  then  reapplying  the  blades. 

Oceipito-Posterior  Position  of  the  Vertex. 

This  position  of  the  vertex  was  considered  in  detail  when  mal- 
positions of  the  child  as  a  cause  of  dystocia  was  being  discussed 
(Chapter  IV.).  I  gave  it  then  as  my  experience  that  rotation  by 
means  of  the  hand  could  be  effected  in  somewhere  about  70  per  cent, 
of  cases,  and  that  it  was  a  most  desirable  proceeding,  as  it  rendered 
the  delivery  of  the  head  infinitely  easier  and  safer  for  mother  and 
child. 

It  sometimes  happens,  however,  that  rotation  is  not  possible,  or 
that  the  malposition  is  overlooked  until  forceps  has  been  applied.  I 
have  already  referred  to  this,  and  indicated  how  one  must  suspect 
the  position  if  there  is  much  difficulty  in  delivering  a  head  at  the 
outlet,  and  especially  if  the  vulvar  orifice  gapes  without  the  perineum 
distending.  I  cannot  agree  with  Barnes  when  he  writes1  against 
manual  rotation  of  the  head,  nor  when  he  states  with  regard  to  forceps 
that  '  delivery  is  nearly  as  easy  as  when  the  instrument  is  applied  to 
an  occipito-anterior  position.'  My  experience  in  delivering  primiparse 
where  the  occiput  remains  persistently  posterior  is  that  a  considerable 
amount  of  force  is  required,  and  that  frequently  a  very  extensive 
tearing  of  the  perineum  results. 

When  rotation  fails  there  is  nothing  for  it  but  the  employment  of 
forceps.  In  this  position  of  the  head,  and  in  this  position  alone, 
straight  forceps  may  be  of  use,  and  there  are  some  of  my  colleagues 
who  carry  that  instrument  solely  for  the  cases  under  consideration. 
The  ordinary  forceps,  however,  with  or  without  the  traction  handles, 
is  quite  suitable,  for  if  rotation  does  occur  it  is  a  simple  matter  to 
remove  the  blades  and  reapply  them.  It  has  been  recommended  to 
apply  the  blades  with  the  pelvic  curve  directed  backwards,  so  that  if 
rotation  occurs  the  blades  are  in  proper  position. 

Seldom  do  I  try  to  rotate  with  the  forceps,  but  if  I  feel  the  instru- 
ment slipping  round  and  the  occiput  coming  to  the  front,  as  it  some- 

1  Op.  cit.,  p.  60. 


858 


OPERATIVE  MlhYYU  l.l;\ 


times  does,  I  encourage  it  to  do  so.  Williams,  Edgar,  and  many 
others,  speak  very  highly  of  actually  rotating  the  instrument  uftei 
having  pulled  the  head  down  and  encouraged  flexion. 

In  occipito-posterior  positions  the  blades  are  introduced  in  tin 
manner  already  detailed.  It  is  most  important  that  the  blades  Bhoufl 
lie  about  equidistant  from  the  occiput  and  sinciput,  otherwise  tln-\ 
are  liable  to  slip  off  suddenly  when  traction  is  exerted. 

In  persistent  occipito-posterior  positions,  the  head  should  U 
delivered  in  the  same  way  as  nature  effects  delivery.  The  sinciput  in 
the  region  between  the  anterior  fontanelle  and  the  glabella  is  pressed 


Fig.  165. — Forceps  in  Persistent  Occipito-Post<  rior  Position  of  Vertex. 


against  the  symphysis,  while  the  occiput  distends  and  finally  swi  i  pe 
over  the  perineum  (Fig.  165).  The  producing  of  flexion  has  the  great 
;i d vantage  that  it  gives  the  head  a  chance  of  rotating  up  to  the  last, 
and  once  or  twice  when  I  thought  all  hope  of  rotation  was  past  I  have 
found  it  occur.  It  is  a  mistake  to  bring  the  occiput  too  far  down 
before  bringing  it  over  the  perineum.  Traction  should  therefore  be 
made  downwards  and  backwards,  then  more  and  more  forwards,  until 
the  occiput  is  born.  The  face  then  slips  down  from  behind  the  sym- 
physis. Very  frequently  I  make  a  lateral  incision  through  the  margin 
of  the  vaginal  orifice,  in  order  to  avoid  perineal  tearing. 


FOIICEPS 


359 


Face  Presentations. 

Forceps  may  be  employed  in  face  presentations,  and  with  very 
satisfactory  results,  provided  the  head  has  passed  the  pelvic  brim  and 
the  chin  is  forwards. 

With  a  normal  pelvis  the  indications  for  the  operation  and  the 
conditions  which  must  be  fulfilled  before  the  instrument  is  applied 
are  in  the  main  identical  to  those  which  obtain  in  vertex  positions 
If,  however,  the  pelvis  is  deformed,  forceps  is  not  a  suitable  instru- 


JFig.  166. — Forceps  in  Face  Presentation. 


ment.  Nor,  indeed,  is  it  advisable  to  attempt  manual  correction  of 
the  position.  Version,  if  that  is  still  possible  and  the  pelvis  is  not  too 
deformed,  is  probably  the  most  suitable  treatment. 

The  position  of  the  blades  in  a  facial  presentation  is  as  the  illustra- 
tion indicates  (Fig.  166).  The  manner  in  which  the  blades  are  inserted 
and  placed  over  the  sides  of  the  face  is,  for  the  most  part,  as  has  been 
already  described.  Special  care  must,  however,  be  taken  not  to  injure 
the  face,  and  to  see  that  the  blades  lie  over  the  sides  of  the  head  in 
a  direction  approaching  the  occipito-mental  diameter.  Consequently, 
the  handles  must  not  be  pushed  too  far  back. 

In  delivering  the  head  one  must  prevent  too  early  descent  of  the 
occiput,  for  if  that  occurs  before  the  chin  comes  below  the  pubes  the 
head  becomes  impacted  in  the  pelvis.  Traction  is  directed,  therefore, 
to  bringing  the  chin  below  and  then  round  the  symphysis.     In  cases 


860  Ol'KKATIN  ]■;  MlhW  \l\.\l\ 

where  the  pelvis  is  normal,  or  only  slightly  deformed,  our  results  from 
forceps  delivery  in  facial  presentations  have  been  very  satisfactory  to 
both  mother  and  child. 

Turning  now  to  mento-poaterior  cases,  1  must  differ  from  Williams 
and  Edgar  and  many  French  and  German  operators  who  refer  to 
forceps  as  being  unsuitable  and  profitless.  A  little  time  ago  we  had  a 
case  which  proved  that,  although  theoretically  such  an  opinion  may 
be  correct,  in  practice  it  is  not  so.  The  patient  had  been  in  the 
second  stage  for  some  hours,  and  it  was  necessary,  both  in  the 
interests  of  mother  and  child,  that  the  delivery  should  be  completed. 
Having  had  previous  experience  of  the  face  rotating  under  the 
influence  of  traction,  my  house-surgeon  made  traction  under  my 
direction,  with  the  result  that  the  chin  came  round  to  the  front  and  a 
living  child  was  delivered  without  difficulty.  Lewers1  some  years 
ago  described  a  similar  experience  in  two  cases,  and  in  the  discussion 
which  followed  Spencer  mentioned  three  in  his  practice.  A  most 
valuable  paper  by  Reed  on  the  subject  recently  appeared  in  the 
American  Journal  of  Obstetrics. 

If  one  fails  to  deliver  the  head  in  a  persistent  mento-posterior 
position  with  forceps,  recourse  to  symphysiotomy  is  not  commendable, 
even  if  the  pelvis  is  of  a  normal  capacity,  for  the  child's  chances  of 
surviving  are  not  good.  In  such  cases,  if  I  could  not  rotate  the  chin 
forwards,  I  would  without  hesitation  perforate  the  head.  The  subject 
of  mento-posterior  position  of  the  face  is  fully  considered  in 
Chapter  IV. 

Brow  Presentations. 

I  consider  forceps  unsuitable  in  brow  presentations.  In  two  cases 
in  my  own  practice  in  which  such  treatment  was  employed,  on  one 
occasion  by  myself  many  years  ago,  and  on  the  other  by  my  house- 
surgeon  recently,  the  results  were  most  unsatisfactory.  After  very 
severe  traction  the  children  were  delivered,  but  both  were  dead. 
Contrast  that  with  the  result  obtained  in  another  case,  where  the 
brow  was  converted  into  a  vertex  position,  and  a  child  weighing 
12  pounds  was  delivered  alive  after  several  fruitless  attempts  had 
been  made  with  forceps  outside  the  hospital  (Chapter  IV. t. 

After-comingr  Head. 

It  is  my  practice  always  to  have   forceps  ready  in   breech   pre- 
sentations, and  to  apply  them  if  after  two  attempts  with  traction  and 
suprapubic  pressure  I  fail   to   deliver   the   after-coming   head.     My 
reasons  for  pursuing  such  a  course    have  been  already  given  when 
1  Trans.  Lond.  Obst.  Soc,  1899,  vol    xli..  p.  '2*0. 


FORCEPS  361 

considering  breech  presentations.  I  never  employ  the  axis-traction 
forceps,  as  the  rods  are  apt  to  get  in  the  way,  especially  the  one 
belonging  to  the  right  or  upper  blade. 

In  carrying  out  the  operation  it  is  an  advantage,  if  an  assistant  is 
available,  to  get  him  to  hold  the  trunk  of  the  child  a  little  forwards, 
so  that  it  may  be  out  of  the  way.     The  introduction  of  the  blades  is 


Fig.  167. — The  Delivery  of  the  After-coming  Head  with  Forceps. 

carried  out  precisely  as  in  other  cases  of  forceps  delivery.  The  trunk 
of  the  child  being  pulled  forwards  out  of  the  way,  the  left  or  lower 
blade  is  passed  along  the  side  of  the  child's  head.  The  right  or 
upper  blade  is  then  passed  into  the  hollow  of  the  sacrum,  and  rotated 
round  into  position  over  the  other  side  of  the  head.  The  blades  must 
always  lie  along  the  ventral  aspect  of  the  child,  so  as  to  promote 


862  OPERATIVE  MIDWIFERY 

flexion  (Pig.  1»»7).  If  they  are  placed  along  the  dorsal  aspect,  any 
fcraotion  extends  the  head.  Traction  should  be  made  first  downwards 
and  backwards,  then  the  forceps  and  child  should  be  carried  upwards 
towards  the  mother's  abdomen. 

Impacted  Breech. 

1  have  once  or  twice  delivered  the  impacted  breech  with  forceps 
when  I  have  been  unable  to  get  my  lingers  into  the  groin,  but  1  have 
more  often  failed  owing  to  the  forceps  slipping.  To  get  a  proper  hold 
of  the  fo?tal  pelvis  the  blades  must  be  applied  to  the  side  of  the 
breech,  with  the  tips  placed  between  the  thigh  and  abdomen  of  the 
child  (Fig.  49).  That,  however,  is  not  always  possible,  especially  if 
the  thighs  are  at  different  levels.  I  cannot,  therefore,  give  the  treat- 
ment a  very  hearty  recommendation,  although  it  is  a  method  I  would 
always  try  before  attempting  to  apply  the  fillet  or  blunt  hook.  The 
introduction  of  the  blades  is  quite  simple,  and  is  carried  out  as  already 
described  for  other  presentations.  The  treatment  of  impacted  breech 
is  fully  considered  in  Chapter  V. 


CHAPTER  XXIV 
FORCEPS— Continued 

Forceps  in  Contracted  Pelvis. 

In  the  last  chapter  I  considered  the  general  principles  that  should 
guide  one  in  the  employment  of  forceps  under  ordinary  conditions. 
There  now  remains  the  very  important  question  of  the  employment  of 
the  instrument  in  contracted  pelvis.,  which  I  have  thought  advisable 
to  discuss  in  a  separate  chapter. 

Few  subjects  in  midwifery  have  given  rise  to  so  much  discussion, 
or  to  such  differences  of  opinion,  as  the  employment  of  forceps  in 
contracted  pelvis.  Even  at  the  present  time  differences  of  opinion 
exist.  As  illustrating  this,  let  me  give  very  briefly  the  views  of  a  few 
representative  Continental  and  American  obstetricians  regarding  the 
matter. 

In  Winckel's  large  work  on  obstetrics  Wyder  says  :  '  The  applica- 
tion of  forceps  is  contra-indicated  so  long  as  the  head  has  not  passed 
the  obstruction,  and  in  general  contracted  pelvis  so  long  as  the  head 
has  not  moulded  itself  to  the  pelvic  deformity.'  Proceeding  further, 
however,  the  writer  admits  that  where  the  life  of  the  mother  or  child 
is  in  danger  an  attempt  may  be  made  with  forceps  even  before  these 
conditions  are  fulfilled. 

Olshausen  and  Veit x  take  a  slightly  broader  view,  for  they  consider 
the  application  justifiable  if  the  greatest  circumference  of  the  head 
is  already  engaged  in  the  brim. 

Ribemont-Dessaignes  and  Lepage2  write  :  '  This  operation,  which 
during  certain  times  has  been  the  subject  of  numerous  discussions, 
has  lost  in  great  part  its  interest,  by  reason  of  the  introduction  of 
symphysiotomy  and  the  almost  complete  abandonment  of  forceps  in 
contracted  pelvis.'  These  writers  recommend  the  application  of 
forceps  only  when  symphysiotomy  is  contra-indicated — for  example, 
when  the  child  is  already  on  the  point  of  dying.     Faraboeuf,  Pinard, 

1  '  Lehrbuch  der  Geburtshulfe,'  5th  edition,  1902,  p.  530. 

2  '  Precis  d'Obstetrique,'  6th  edition,  1904,  p.  1122. 

863 


864  OPERATIVE   MII>\\  Il'KkY 

and  French  obstetricians  generally,  are  opposed  to  pulling  the  head 
past  the  obstruction. 

Bdgar  of  New  York1  writes:  '  The  greatest  circumference  of  the 

head  roust  have  passed  the  inlet,  and  the  head  must  he  fixed  in  the 
pelvis';  but  when  speaking  of  forceps  in  contracted  pelvis  he  says:2 
4  Forceps  application  is  applicable  to  those  cases  in  which  the  head 
is  engaged,  or  in  which  it  can  be  made  to  engage  by  suprapubic 
pressure,  or  in  which  it  is  possible  to  be  sure  that  there  is  no 
disproportion  between  the  head  and  the  pelvis.' 

Williams3  says:  'Generally  speaking,  contracted  pelvis  presents 
an  absolute  contra-indication  to  the  application  of  forceps,  for  if  the 
contraction  be  marked  it  will  be  impossible  to  drag  the  head  through 
the  pelvis,  and  if  brute  force  be  employed  it  will  result  in  the  death  of 
the  child,  and  severe  injuries  to  the  soft  parts  of  the  mother,  and 
occasionally  cause  her  death.  On  the  other  hand,  when  the  contraction 
is  slight — and  especially  when  the  head  is  already  engaged  in  the 
upper  part  of  the  pelvic  cavity — a  tentative  application  with  forceps 
may  be  justifiable.  Under  such  circumstances  a  few  tractions  of 
moderate  intensity  should  be  made  ;  if  the  head  follows  them,  they 
should  be  continued,  but  if  not  the  forceps  should  be  removed,  and 
delivery  effected  in  some  other  manner.' 

Of  these  writers,  Williams  is  undoubtedly  the  most  explicit,  and 
his  attitude  towards  this  subject  is  clear  and  well  defined.  The  others, 
with  the  exception  of  a  certain  school  in  France,  who  condemn  entirely 
the  application  of  forceps  before  the  greatest  circumference  of  the 
head  has  passed  the  brim,  evade  the  real  question  at  issue.  "While 
condemning  the  pulling  of  the  head  past  the  obstruction,  they  are 
forced  to  admit  that  it  must  be  done  under  certain  circumstances. 
Personally,  I  am  in  entire  agreement  with  Williams,  and  I  think  his 
summing-up  of  the  matter  in  the  few  words  already  quoted  is  excellent. 

In  recent  years  one  or  two  German  writers  have  expressed  similar 
views.  Both  Skutsch4  and  Nagel5  recommend  the  bringing  of  the 
head  past  the  obstruction  with  moderate  traction.  Nagel6  writes: 
*  Only  those  can  term  the  high  forceps  barbarous  who  have  had 
little  practice  with,  and  have  incompletely  mastered,  the  operation. 
In  truth  it  is  now  the  most  skilful  of  all  the  obstetric  operations.' 
Wenczel 7  and  T6ths  have  made  two  important  contributions  on  the 
subject  of   high  forceps  in  contracted  pelvis.     The  attitude    that  it 

1  '  Practice  of  Obstetrics,'  1903,  p.  1016.  -  Ibid.,  p.  698. 

3  '  Obstetrics,'  1903,  p.  358. 

4  'GeburtshiilHiche  Operationslehere,'  Jena,  1901. 

5  'Operative  Geburtshiilfe,'  Berlin,  1902.  '    Ibid.,  p.  221. 

"  Archiv  f.  Gyn.,  1904,  lxxiii.,  p.  673.  -  Ibid.,  J5d.  lv..  p.  11. 


FORCEPS  365. 

is  permissible  to  pull  the  child's  head  past  the  obstruction  appears  to 
me  the  only  rational  one,  for  otherwise  how  can  one  avoid  performing 
symphysiotomy,  pubiotomy,  or  Cesarean  section  unnecessarily  ?  Every 
one  knows  that  there  are  many  cases  in  which  only  a  little  traction  is 
required  to  bring  the  head  through  the  brim.  Is  one  to  perform, 
symphysiotomy,  pubiotomy,  or  Cesarean  section  in  such  cases  '?  So 
much  for  the  extreme  position  that  forceps  is  not  to  be  applied  until 
the  child's  head  has  passed  the  obstruction. 

But  there  is  the  other  extreme  position  of  those  who  employ 
brute  force  to  bring  the  child  through  the  contracted  brim.  Admitting 
that  it  is  sometimes  permissible  to  pull  the  head  past  a  bony  obstruc- 
tion of  the  pelvis  with  forceps,  it  must  be  clearly  understood  that  this 
obstruction  must  be  slight,  and  that  the  amount  of  force  employed 
must  be  very  moderate.  Unfortunately,  at  present  this  is  not  fully 
appreciated.  Practitioners  drag  at  the  child's  head  with  forceps,  and 
proudly  boast  how,  with  their  feet  against  the  bed  or  couch,  or  even- 
against  the  pelvis  of  the  mother,  they  have  pulled  children  through 
the  most  contracted  brims.  Practitioners  not  infrequently  say  to  me 
that  they  have  never  seen  cases  of  contracted  pelvis  in  which  they 
could  not  deliver  the  child  with  forceps.  Every  week  we  receive  into 
the  Glasgow  Maternity  Hospital  cases  of  contracted  pelvis  in  which 
practitioners  have  failed  to  deliver  with  forceps. 

"What  are  the  reasons  for  this  state  of  matters  ?  and  who  are  to 
blame  for  this  unfortunate,  but  far  too  common,  practice  ? 

In  great  part  obstetric  teachers  have  been  to  blame.  Let  me 
indicate  what  I  mean  by  a  specific  example.  An  important 
discussion  on  the  employment  of  forceps  in  contracted  pelvis  took 
place  at  the  annual  meeting  of  the  British  Medical  Association  m 
Carlisle  in  August,  1896. 1  The  discussion  was  introduced  by  the  late 
Milne  Murray,  who  was  then  recognized  as  a  great  British  authority 
on  forceps.  Milne  Murray  then  said  :  '  During  the  last  eight  years  I 
have  delivered  living  children  in  several  cases  where  the  brim  was  not 
more  than  3|  inches,  and  in  one  case,  already  on  record,  I  delivered  a 
living  child  where  accurate  measurements  of  the  pelvis  made  post- 
mortem and  under  chloroform  showed  that  the  conjugate  was  not 
more  than  2-75  inches.  In  this  case  the  head  was  quite  free  when  the 
forceps  were  applied — indeed,  it  had  to  be  steadied  by  an  assistant 
during  their  application.' 

The  harm  which  has  followed  such  teaching  is  incalculable.  It 
will  be  many  years  before  it  is  generally  recognized  as  being  unsound 
and  unscientific.     Speaking  for  myself,  it  is  only  from  the  experience 

1  Brit.  Med.  Journ.,  October  31,  1896,  vol.  ii.,  p.  1282. 


866  OPERATIVE  MIDWIFERY 

gained  in  the  last  few  years  in  the  Glasgow  Maternity  Hospital  that 

I  have  rcali/cd  it — indeed,  J  have  only  fully  done  so  since  I  examined 
our  results  from  the  treatment  and  discovered  how  very  unsatisfactory 
they  are.  Let  me  give  these  results.  Here  is  a  table,  which  includes 
all  cases  of  pelvic  deformity,  where  the  conjugata  vera  measured 
3k  to  3  inches  (H-7  to  75  centimetres),  delivered  by  forceps  in  the 
•Glasgow  Maternity  Hospital  during  the  years  18'J'J  to  1906  inclusive. 
The  cases  number  130  in  all. 

Table    of    130    Casks,    whkuk    Conjugata    Vera    measured    3J    i"    :;    [scuba 
3*7    i"    7*5   Centimetres),    delivered    bt    Forceps    in    Glasgow    Maternity 

Bospital,    1899  TO  1906. 


In.  (7*5  cm.),  80  Oases.  C.V.  S\  In.  (8.  cm.]        I  C.V. 


Alive,  21.        Dead,  18.  Alive,  40.        Dead,  12  Alive.  33.  Dead,  6. 

tVetal  mortality,  46  %.  Foetal  mortality,  23  %.  Foetal  mortality 


I  need  hardly  say  that  these  results  are  far  from  satisfactory. 
Many  of  the  cases,  without  doubt,  were  interfered  with  before  admis- 
sion to  hospital,  but  excluding  the  fatal  cases  that  we  in  the  hospital 
were  not  responsible  for,  the  fcetal  mortality  is  far  too  high.  If 
such  are  the  results  obtained  by  my  colleagues  and  myself  in  the 
hospital,  who  have  had  so  much  experience  with  forceps  in  contracted 
pelvis,  and  have  every  convenience  for  performing  the  operation,  it 
may  safely  be  concluded  that  worse  results  will  follow  a  similar  treat- 
ment practised  by  those  who  only  occasionally  encounter  cases  of 
pelvic  deformity. 

In  employing  forceps  in  contracted  pelvis  two  great  mistakes  are 
made  :  (1)  Insufficient  time  is  given  the  head  to  mould ;  (2)  forceps  is 
employed  in  degrees  of  pelvic  deformity  in  which  it  is  quite  profitless  to 
employ  the  instrument.  I  have  said  sufficient  about  the  first  mistake 
elsewhere.  I  have  pointed  out  that  the  second  stage  should  be  allowed 
to  continue  three,  four,  five,  six,  or  even  more  hours,  and  that  the 
condition  of  the  mother  and  child  should  be  watched,  and  inter- 
ference had  recourse  to  only  when  there  are  decided  indications  for 
doing  so. 

The  second  mistake  is  well  illustrated  by  the  table.  As  shown, 
the  foetal  mortality  is  as  high  as  46  per  cent,  with  a  conjugata  vera  of 
3  inches  (7'5  centimetres).  It  must  be  admitted,  therefore,  that  with 
such  a  degree  of  deformity  it  is  unwise,  except  in  very  exceptional 
circumstances,  to  employ  forceps.  I  am  perfectly  well  aware  that 
there  are  cases  on  record  where  living  children  have  been  delivered 
through  a  pelvis  of  2|  inches  (7  centimetres).     Milne  Murray  and 


FOltCEPS 


367 


others  have  recorded  cases,  and  in  the  hospital  we  have  had  such 
cases ;  but  they  are  of  great  rarity,  and  should  not  come  into 
■consideration  or  influence  one  in  favour  of  forceps.  I  have  stated 
that  under  exceptional  circumstances  the  operation  may  be  justifiable 
with  the  degree  of  deformity  we  are  considering — viz.,  3  inches.  If, 
for  example,  the  head  is  found  well  engaged  and  moulded,  and  seems 
only  very  slightly  larger  than  the  pelvic  brim,  and  provided  the  type 
of  pelvis  is  of  the  fiat  variety,  one  may  make  an  attempt  in  the 
Walcher  position  with  the  forceps  prior  to  performing  pubiotomy  or 
craniotomy  ;  but,  let  me  again  remark,  rarely  will  one  succeed  in  such 
cases  with  moderate  traction. 


Flu.  168. — Oblique  Grasp  of  the  Head,  showing  the  Position  of  the  Blade  situated  over 

the  Face. 


Take  now  pelves  less  deformed.  As  might  naturally  be  expected, 
with  increasing  pelvic  capacity  the  fcetal  mortality  proportionately 
■decreases.  Thus  from  the  table  it  will  be  seen  that  at  3]  inches  it  is 
23  per  cent.,  and  at  3|-  inches  it  is  15  per  cent.  No  hard-and-fast  rules 
can  be  laid  down  regarding  the  employment  of  forceps  in  such  degrees 
of  medium  deformity  ;  the  only  guide  must  be  the  relative  size  of  the 
head  and  the  pelvis.  In  certain  cases  with  a  pelvis  of  3^  inches  it 
may  be  absolutely  sound  treatment  to  employ  forceps,  while  in  other 
cases  with  a  deformity  of  Sh  inches  it  may  be  equally  unsound. 

When  is  one  justified  in  such  cases  in  using  forceps?  It  is  easier 
to  answer  this  by  stating  under  what  conditions  one  is  not  justified. 

1.  One  is  not  justified  in  applying  the  instrument  until  the  head 


368 


OPERATIVE   MIDWIFERY 


has  been  given  the  utmost  limit  of  time  to  mould.  By  the  utmost 
limit  of  lime  1  mean  until  symptoms  of  disturbance  in  the  mother  or 
embarrassment  in  the  foetal  circulation  arise. 

-.  One  is  not  justified  in  applying  forceps  if  the  head  is  freely 
movable  above  the  brim  and  if  there  is  distinct  overlapping  after  the 
head  has  been  allowed  this  long  time  to  mould. 

:'..  One  is  not  justified,  or  at  least  one  will  find  it  profitless,  to 
apply  forceps  in  posterior  parietal  (Litzmann's  obliquity)  presentations 
(p.  163). 

4.  One  is  not  justified  in  continuing  attempts  at  forceps  delivery 
after  two  failures  with  a  moderate  degree  of  traction  and  the  patient  in 
the  "Walcher  position. 


Fl.: 


169. — Oblique  Grasp  of  the  Head,  showing  the  Position  of  the  Bla<l"  situated 
over  the  Occiput. 


Application  of  Forceps  in  Flat  Pelvis.— "When  the  head  is 
arrested  at  the  brim  in  a  fiat  pelvis,  it  will  be  found  lying  with  its 
long  axis  in  the  transverse  diameter.  Consequently,  the  blades,  if 
they  are  simply  slipped  into  the  sides  of  the  pelvis  without  considering 
the  child's  head,  will  generally  grasp  the  head  obliquely  (Fig.  U 
although  they  may  accidentally  grasp  the  head  antero-posteriorlv. 

The  fact  that  this  antero-posterior  grasp  of  the  fa-tal  head  has 
always  been  considered  so  unsatisfactory  has  led  several  obstetricians 
to  recommend  the  application  of  the  blades  to  the  transverse  diameter 
of  the  child's  head,  and  consequently  in  the  antero-posterior  diameter 
of  the  pelvis. 


FORCEPS  369 

There  are,  therefore,  three  distinct  methods  of  applying  the  forceps 
in  flat  pelvis  : 

1.  The  casual  slipping  of   the    blades  into   the  sides  of  the 

pelvis,  and  grasping  the  head  obliquely. 

2.  The   deliberate   application   of   the  blades — one   over  the 

occiput,  the  other  over  the  face. 

3.  The  deliberate  application  of  the  blades  antero-posteriorly 

as  regards  the  pelvis — one  blade  in  front  of  the  promon- 
tory, and  the  other  behind  the  symphysis. 

1.  The  Casual  Slipping-  of  the  Blades  into  the  Sides  of  the 
Pelvis  and  Grasping1  the  Head  Obliquely.— This  is  the  method 
generally  employed,  and  it  is  certainly  the  easiest  (Fig.  169).  The 
instrument  often  slips,  however,  although  in  many  cases  the  hold 
is  quite  satisfactory.  All  one  has  to  do  is  to  apply  the  instrument 
as  described  in  the  previous  chapter.  When  the  blades  are  locked, 
the  handles  often  gape  very  considerably,  so  that  in  order  to  obtain 
a  firm  hold,  the  butterfly  screw  must  be  tightened  firmly. 

Having  applied  the  blades,  tentative  traction  is  made ;  if  the 
instrument  holds,  good  and  well ;  if  it  slips,  the  blades  are  reapplied. 
It  has  always  appeared  to  me  a  haphazard  way  of  employing  the 
instrument,  so  that  I  invariably  try  to  employ  the  second  method, 
now  to  be  considered  : 

2.  The  Deliberate  Application  of  the  Blades— One  over  the 
Occiput,  the  Other  over  the  Face. — This  is  a  method  of  applying 
the  blades  which  is  usually  condemned,  and  although  personally  I 
approve  of  it  and  practice  it,  I  do  not  feel  justified  in  emphatically 
recommending  it,  seeing  that  so  many  of  the  most  distinguished 
obstetricians  since  the  time  of  Smellie  and  Baudelocque  have  con- 
demned it.  With  the  exception  of  the  Edinburgh  school,  there  are 
few  supporters  of  the  method  of  employing  the  forceps  so  that  the 
blades  lie  directly  over  the  occiput  and  face.  I  believe,  however,  that 
most  of  the  objections  to  this  mode  of  application  are  theoretical,  and 
are  advanced  by  those  who  have  not  had  experience  of  the  instrument 
employed  in  this  way. 

In  employing  this  method  it  is  well  to  have  the  patient  in  the 
dorsal  decubitus.  The  left  blade,  after  its  introduction  into  the 
vagina,  is  passed,  not  directly  over  the  part  of  the  foetal  head  against 
which  it  is  ultimately  to  lie,  but  is  guided  by  the  hand  in  the  vagina 
up  towards  the  sacro-iliac  synchondrosis,  and  then  rotated  over  the 
face  or  occiput  as  the  case  may  be.  The  right  blade  is  then  passed 
into  the  hollow  of  the  sacrum  and  rotated  round  to  the  other  side  of 
the  pelvis,  and  it  likewise  is  placed  directly  over  the  other  extremity 

•24 


370  <>h:i;ati\  i:  midwjfkiiy 

of  thu  Long  axis  of  the  head  (Pig.  170).  Tlie  placing  of  the  hlades 
exactly  in  position  is  by  no  means  easy,  and  I  must  candidly  admit 
that  I  have  frequently  failed,  and  got  a  slightly  oblique  instead  of  an 
exact  antero-posterior  grip  of  the  head.  It  hus  always  appeared  to  me, 
however,  even  in  the  cases  in  which  I  have  failed  to  get  the  blades 
applied  exactly  as  I  wished,  that  I  secured  a  better  grasp  of  the  head 
than  if  1  had  simply  casually  slipped  in  the  instrument  and  trusted  to 
the  hold  obtained.  The  locking  of  the  hlades  is  sometimes  attended 
with  a  little  difficulty,  as  the  handles  gape  very  widely.  It  is  necessary 
to  tighten  the  butterfly  screw  firmly. 

The    blades  being  locked,  traction    should  now  be   made  to 
if  the  instrument  is  holding;   this  being  considered  satisfactory,  it 


FlG.  170.— Application  of  Blades  of  Forceps,  with  One  Blade  over  the  Face  and  the 

other  over  the  Occiput. 

is  advisable  to  place  the  patient  in  the  Walcher  position.  The 
operator  now  sits  upon  the  floor  (Fig.  171).  That  I  have  found 
absolutely  necessary  if  the  full  benefit  of  the  axis-traction  forceps  in 
the  Walcher  position  is  to  be  obtained.  He  then  pulls  directly  in  the 
axis  of  the  brim.  One  or  two  attempts  at  pulling  the  head  past  the 
obstruction  is  all  that  is  permissible,  and  the  amount  of  force  that 
the  operator  exerts  must  not  be  extreme  ;  it  must  not  be  more  than 
can  be  exerted  by  his  forearms.  In  the  majority  of  cases,  if  one  has 
carefully  estimated  the  relative  size  of  the  head  and  the  pelvis  and 
conformed  to  all  the  conditions  already  laid  down,  the  head  will  | 
through.     In  flat  pelvis  it  does  so  sometimes  with   a  sudden  jerk, 


FORCEPS 


871 


which,  on  the  first  occasion  the  sensation  is  experienced,  may  alarm 
the  operator  ;  but  it  is  of  no  consequence,  and  simply  means  that  the 
head  has  passed  into  the  roomy  part  of  the  pelvis. 

The  forceps  is  now  removed.  To  continue  the  extraction  with 
it  still  in  the  antero-posterior  diameter  of  the  head  would  be  a  distinct 
error  in  technique,  for  one  would  then  be  dragging  the  longest 
diameter  of  the  head  through  the  narrowest  diameter  of  the  pelvis. 
The  blades  must,  therefore,  be  reapplied  in  the  ordinary  way.     I  have 


Fig.  171. — Axis-Traction  Forceps  with  Head  fixed  at  the  Brim. 
The  patient  is  in  the  Walcher  position,  and  the  operator  is  sitting  on  the  floor. 

sometimes  found  that  if  I  reapplied  the  blades  immediately,  I  obtained 
■the  same  grip  of  the  head,  for  it  had  not  rotated.  It  is,  I  think, 
better,  therefore,  after  removing  the  blades,  to  stimulate  the  uterus  to 
contract,  to  exert  firm  pressure  upon  the  uterus  when  it  does  so,  and 
to  rotate  the  head  into  the  conjugate  diameter  with  the  hand  in  the 
vagina  before  reapplying  the  instrument.  Delivery  is  then  completed 
in  the  ordinary  way. 


372 


OPERATIVE  MIDWIFERY 


3.  The  Deliberate  Application  of  the  Blades  Antero-Posteriorly 
as  regards  the  Pelvis— One  Blade  in  front  of  the  Promontory 
and  the  Other  behind  the  Symphysis. — This  is  the  method  em- 
ployed by  the  old  obstetricians,  and  careful  instructions  regarding 
such  an  application  will  be  found  in  the  writings  of  Baudelocque, 
Smellie,  etc.  At  the  present  time  it  is  still  employed  by  a  few 
obstetricians  in  France,  but  in  all  other  countries  it  has  been  entirely 
abandoned,  the  previous  methods  described  being  preferred. 

Several  obstetricians — for  example,  Sloan,  Reid,  and  Cameron  of 
Glasgow,  and  Fry  in  America — have  invented  forceps  the  blades  of 
which  lie  antero-posteriorly  as  regards  the  maternal  pelvis.  The 
object  of  such  forms  of  antero-posterior  forceps  is,  of  course,  to  obtain 
a  transverse  grasp  of  the  child's  head.  Here  is  an  illustration  of 
Cameron's  forceps  (Fig.  172).     It  is  at  once  evident,  that  the  position 


Fig.  172. — Cameron's  Forceps. 


of  the  blades  antero-posteriorly  must  be  a  source  of  considerable 
danger  to  the  parturient  during  extraction,  and  especially  must  there 
be  great  danger  to  the  soft  parts  situated  over  the  promontory. 
Antero-posterior  forceps,  therefore,  has  not  been  received  with  any 
favour,  and  is  not  likely  to  become  more  popular  in  the  future. 

An  instrument  somewhat  similar  in  principle  to  Cameron's  forceps, 
but  much  more  complicated,  is  the  prehenseur-levier-mensurateur  of 
Farabceuf  (Fig.  173). 

Forceps  in  Generally  Contracted  Pelvis. —  In  suitable  cases 
forceps  is  most  useful.  In  this  variety  of  pelvic  deformity  it  must 
never  be  employed  unless  the  head  is  well  fixed  at  the  brim  and 
there  is  no  overlapping.  The  presence  of  an  unusually  large  caput 
may  sometimes  render  it  difficult  to  say  how  much  of  the  head  has 
really  passed  the  brim,  but  by  careful  palpation  along  the  brim  one 
can  always  tell  the  relative  size   of   head  and   pelvis.     It   must   be 


FORCEPS 


373 


remembered,  however,  that  a  relatively  less  amount  of  disproportion 
can  be  overcome  in  a  generally  contracted  pelvis  than  in  a  flat  pelvis. 
In  a  generally  contracted  pelvis  we  have  seen  that  the  head  engages 
in  the  oblique  diameter  of  the  pelvis  and  is  very  much  flexed. 
The  application  of  the  blades  is,  as  has  been  already  described,  for 
cases  where  the  head  is  high  in  the  cavity,  except  that  the  blades 
must  be  brought  well  forward,  otherwise  they  are  very  apt  to  slip  off. 
The  Walcher  position  is  of  no  advantage  in  the  pure  varieties  of 
generally  contracted  pelvis. 

Maternal  and  FoGtal  Mortality  and  Morbidity.  —  The  maternal 
mortality  in  my  cases  was  l-4  per  cent.,  which  does  not  appear  a  very 


Fig.  173. — Prehenseur-levier-mensurateur.     (Farabceuf.) 


high  figure.  I  would  remark,  however,  that  several  of  the  fatal  cases 
of  craniotomy,  which  are  mentioned  in  connexion  with  that  operation, 
were  really  the  result  of  injudicious  use  of  forceps.  The  same  remark 
also  applies  to  the  maternal  morbidity,  which  works  out  at  20  per  cent. 
That  figure  in  no  way  represents  the  proportion  of  cases  in  which 
injuries  to  the  parturient  canal  resulted  from  the  injudicious  use  of 
forceps. 

I  have  already  said  sufficient  about  the  festal  mortality 
(Chapter  XII.).  The  morbidity  also  is  very  high ;  bruises  and  lacera- 
tions of  the  soft  parts,  indentations  and  fractures  of  the  bones,  and 
injuries  to  eyes,  ears,  nerves,  are  by  no  means  uncommon.  These 
injuries  are  considered  in  Chapter  XXXVII. 


CHAPTER  XXV 

THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY— 
SYMPHYSIOTOMY  AND  HEBOSTEOTOMY  (PUBIOTOMY) 

The  operation  of  symphysiotomy  has  had  a  most  chequered  history. 
Although  performed  upon  the  dead  as  an  alternative  to  post-mortem 
Cesarean  section  by  Claude  de  la  Courvee  in  1655,  it  is  invariablv 
associated  with  the  name  of  Sigault,  who  suggested  it  in  1768,  and 
performed  it  for  the  first  time  in  1777.  The  result  of  Sigault's 
operation  was  in  the  main  satisfactory,  for  the  child  was  born 
alive.  The  woman  had  previously  given  birth  to  four  stillborn 
children.  She  suffered  for  the  remainder  of  her  life  from  a  urinary 
fistula.1 

In  the  succeeding  years  symphysiotomy  was  performed  many 
times.  Baudelocque,2  a  strong  opponent  of  it,  wrote  :  '  It  was 
performed  more  times  in  the  space  of  four  or  five  years  than  the 
Cesarean  operation  had  been  in  the  course  of  twenty  or  thirty,  or 
perhaps  in  half  an  age.'  Its  popularity  was  short-lived,  however.  In 
France  it  was  soon  entirely  abandoned,  although  in  Italy  it  lingered 
on,  and  was  occasionally  performed. 

After  an  interval  of  about  one  hundred  years  interest  was  again 
aroused  in  it,  and,  as  might  be  expected,  Italy  furnished  the  prime 
movers  in  the  revival.  The  obstetrician  most  prominently  associated 
with  this  revival  was  Morisani. 

Encouraged  by  Morisani's  results,  it  soon  met  with  the  support  of 
many  distinguished  obstetricians  in  other  countries,  chief  amongst 
these  being  Pinard,  Yarnier,  and  Bar,  in  France,  and  Zweifel  in 
Germany.  Little  wonder,  therefore,  that  in  a  few  years  symphysi- 
otomy once  again  came  to  be  the  most  burning  question  in  obstetrics. 
In  France  and  Germany  during  the  last  decade  of  the  nineteenth 

1  Zweifel,    'Die    Symphyseotonrie,'    1893;    and    Fasbender,    '  Geschichte    der 
Geburtshulfe,'  1906. 

2  Heath's  translation,  vol.  in.,  p.  241. 

374 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY      375 

century  it  was  constantly  being  discussed,  and  at  the  International 
Medical  Congress  in  1894,  and  again  in  1897,  it  was  the  principal 
subject  under  consideration  in  the  Obstetrical  Section.  The  operation 
never  has  aroused  much  interest  in  this  country  or  in  America. 
Valuable  communications  have  been  made  by  Herman,1  Buist,2 
Jewett,3  and  others,  but  there  have  been  no  enthusiastic  partisans, 
as  in  France  and  Germany.  We  have  for  the  most  part  been 
onlookers. 

A  year  or  two  ago  it  appeared  as  if  history  were  going  to  repeat 
itself,  and  the  operation  were  again  to  be  forgotten.  Quite  suddenly, 
however,  interest  was  aroused  by  the  introduction  by  Van  der  Velde  and 
Gigli  of  pubiotomy,  or  as  it  is  often  termed  hebosteotomy.  This  opera- 
tion is  considered  later  (p.  398). 

General  Considerations. — The  object  of  both  symphysiotomy  and 
pubiotomy  is  to  enlarge  the  pelvic  capacity,  so  that  a  living  child  may 
be  delivered  without  any  great  difficulty  per  vias  naturales.  Their 
indication,  therefore,  is  a  certain  degree  of  pelvic  deformity  ;  the  exact 
degree  we  shall  consider  later.  It  has  been  claimed  that  these  opera- 
tions might  occasionally  be  of  value  in  persistent  mento-posterior 
positions  of  the  face  and  in  brow  presentations.  Everyone  is  agreed 
that  it  would  be  unwise  to  make  a  routine  practice  of  the  operations  in 
such  conditions,  but  recently  I  was  forced  to  admit  to  myself  that 
occasionally  they  were  justifiable.  The  case  which  converted  me  to  this 
view  was  a  brow  presentation  admitted  to  hospital  advanced  in  labour 
which  I  could  not  convert  to  a  vertex  or  deliver  with  forceps  without 
using  brute  force.  The  child's  heart  sounds  were  regular  and  strong, 
and  so  I  proceeded  to  perform  pubiotomy.  The  result  was  most 
satisfactory  both  as  regards  mother  and  child. 

As  a  result  of  division  of  the  symphysis  or  pubes,  all  the  pelvic 
diameters  are  increased.4  Formerly  it  was  thought  that  this  occurred 
by  a  simple  rotation  of  the  bones  outwards ;  it  is  now  known,  however, 
that  the  innominate  bones,  when  separated,  rotate,  not  only  outwards, 
but  downwards,  for  the  sacro-iliac  joints — the  hinges,  if  we  compare 
the  innominate  bones  to  two  folding  doors — do  not  lie  parallel  to  the 
divided  ends  of  the  pubic  joint.  All  recent  writers  have  referred  to 
this,  and  the  general  opinion  is  that  with  3  centimetres  of  pubic 
separation  there  is  a  descent  of  2  centimetres.  The  most  valuable 
paper  on  this  subject  in  the  English  language  is  by  Sandstein,5  who 

1  Trans.  Lond.  Obst.  Soc,  1900,  vol.  xlii.,  1900,  p.  282. 

2  Trans.  Edin.  Obst.  Soc,  vol.  xxvii.,  p.  112. 

3  Amer.  Journ.  Obst.,  vol.  xliv.,  1901. 

4  The  pelvic  capacity  is  increased  to  an  equal  extent  in  both  operations. 
6  Trans.  Edin.  Obst.  Soc,  1902,  p.  68. 


876  OPERATIC  E  M 1 1  >\\  1 1  i:i;V 

made  careful  measurements  of  the  pelves  of  twenty-eight  female 
cadavers  upon  whom  he  performed  symphysiotomy.  Bandetein 
believes  that  the  increase  of  the  pelvic  capacity  results  more  from  the 
movement  downwards  than  from  the  rotation  outwards. 

As  regards  the  amount  of  gain  in  the  conjugata  vera,  Sandstein 
says:  'Roughly  speaking,  (J  centimetres  (2-:*4  inches)  of  pubic 
separation  gives  an  increase  of  1  centimetre  (0*89  inch'.  Morisani 
found  with  (5  centimetres  separation  a  gain  of  1*8  to  1*5  centimetres.' 
Jewett '  writes  :  '  With  a  pubic  separation  of  7  centimetres  the  total 
gain  in  the  antero-posterior  diameter  is  about  1*8  centimetres  ;  in  the 
transverse  the  gain  is  1*5  centimetres  ;  and  in  the  oblique  about  twice 
as  much  as  in  the  conjugate.'  Doderlein,  from  his  experiments,2 
states  that  he  found  the  pelvic  ring  increased  from  105  .jcm.  to 
155  qcm.,  with  0  centimetres  of  separation  (the  conjugata  vera  was 
10"2  centimetres;.  Wehle:!  considers  that  with  a  separation  of 
6  centimetres  there  is  an  increase  of  1*2  centimetres,  and  with  a 
separation  of  7  centimetres  an  increase  of  1*5  centimetres. 

Generally  speaking,  these  different  observers  are  pretty  well  agreed 
as  regards  the  amount  of  separation  necessary  to  obtain  a  gain  of 
1  centimetre  in  the  conjugata  vera.  Curiously  enough,  however, 
Farabceuf  and  Sandstein  arrived  at  exactly  opposite  conclusions  when 
the  initial  size  of  the  pelvis  is  considered,  for  Farabu-uf  found  that  the 
larger  the  pelvis  the  less  was  the  increase,  while  Sandstein  states  '  The 
larger  the  true  conjugate,  the  greater  the  increase  for  each  centimetre 
of  separation.'  In  this  matter  I  attach  more  importance  to  Farabceuf  s 
results,  for  Sandstein  seems  to  have  experimented  only  upon  cases 
where  the  pelvis  was  normal.  He  says,  '  The  conjugata  vera  averaged 
11*28  centimetres  '  (4*5  inches). 

But  there  is  another  factor  besides  the  increase  of  the  pelvic 
capacity  which  favours  the  passage  of  the  head  after  symphysiotomy, 
and,  with  the  exception  of  Sandstein,  all  writers  are  agreed  regarding 
its  importance.  It  is  the  bulging  of  the  anterior  parietal  bone  into 
the  gap  between  the  separated  pubic  bones.  In  certain  cases  of 
obliquely  deformed  pelvis  this  cannot  occur  ;  but  such  cases  are  not 
common. 

1  '  Practice  of  Obstetrics,'  1902,  p.  747. 
*  Zent.f.  Gyn.,  1893,  No.  23,  p.  490. 
Arbeit,  aus  Her  Kiiniylichcn  Fnmenldinik  in  Dresden,  1892,  vol.  i.,  p.  :;7  I. 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY      377 

Conditions  which  must  be  Fulfilled  before  Symphysiotomy 
or  Pubiotomy  is  Contemplated. 

Before  the  operation  of  symphysiotomy  or  pubiotomy  is  contem- 
plated the  following  conditions  must  be  fulfilled  : 

1.  The  child  must  be  alive. 

2.  The  pelvis  must  be  of  sufficient  size,  and  there  must  not 

be  too  great  a  disproportion  between  it  and  the  fcetal 
head. 

3.  The  passage  must  be  well  dilated. 

4.  The  parturient  canal  must  not  be  infected. 

1.  The  Child  must  be  Alive. — Not  only  must  the  child  be  alive, 
but  the  foetal  heart  sounds  should  be  regular,  strong,  and  of  normal 
frequency.  To  subject  a  woman  whose  child's  vitality  is  already  very 
decidedly  impaired  to  the  risks  of  symphysiotomy  or  pubiotomy  serves 
no  purpose,  for  the  child  will  very  probably  not  be  saved,  and  the 
mother's  life  will  be  much  more  endangered  than  if  one  performed 
craniotomy.  If  the  pelvic  deformity  is  such  as  to  permit  of  sym- 
physiotomy or  pubiotomy,  craniotomy  can  be  carried  out  with  the 
greatest  ease,  and  with  little  risk  to  the  patient's  life  or  her  future 
comfort  and  health.  Consequently,  it  is  clearly  the  operation  which 
should  be  chosen.  Some  obstetricians  refuse  to  perforate  a  living 
child  under  any  circumstances,  but  I  have  no  sympathy  with  such 
an  extreme  attitude.  As  I  shall  explain  in  connexion  with  Cesarean 
section  and  craniotomy,  it  is  occasionally  better  for  the  individual,  the 
family,  and  the  State  to  perforate  a  living  child,  especially  if  its  life 
has  been  decidedly  endangered. 

In  difficult  craniotomies  it  has  been  suggested  that  the  delivery  of 
the  child  might  be  facilitated  by  performing  symphysiotomy  or  pubi- 
otomy. Although  such  a  procedure  is  extremely  undesirable,  it  is 
conceivable  that  an  operator  might  be  justified  in  having  recourse 
to  it.  Suppose,  for  example,  the  accoucheur  performs  craniotomy 
and  cannot  get  the  child  extracted  ;  such  a  misfortune  might  happen 
if  he  had  not  appreciated  the  real  extent  of  the  pelvic  deformity.  The 
operator  in  such  a  plight,  with  a  perforated  child  he  cannot  extract, 
has  nothing  left  but  to  perform  symphysiotomy  (pubiotomy)  or 
Cesarean  section,  and  I  can  quite  understand  that  he  might  prefer 
symphysiotomy.  Before  adopting  such  a  course,  however,  he  must 
make  very  sure  that  the  pelvic  capacity  is  such  as  to  allow  the 
perforated  head  to  pass.  Some  time  ago  I  read  of  a  case  in  point 
where  the  accoucheur,  after  performing  craniotomy  and  symphysi- 
otomy, had  finally  to  have  recourse  to  Cesarean  section  ! 


378  OPERATIVE   MlhWllT.KY 

Here,  also,  Lei  me  Bay  that  it  is  undesirable  to  combine  symphysi- 
otomy or  pubiotomy  with  induction  of  premature  Labour,  as  has  been 
once  or  twice  BUggested.  If  the  premature  infant  cannot  be  extracted 
with  forceps,  it  is  injudicious  to  subject  the  mother  to  the  risks  of 
symphysiotomy  or  pubiotorny  for  the  sake  of  a  premature  child,  whieh, 
even  under  the  most  favourable  conditions,  has  but  a  feeble  hold  of 
life. 

2.  The  Pelvis  must  be  of  Sufficient  Size,  and  there  must  not  be 
too  great  a  Disproportion  between  it  and  the  Foetal  Head.  In 
discussing  this  most  important  matter,  let  me  first  of  all  indicate  the 
extreme  limit  of  pelvic  deformity  at  which  the  operations  may  be 
performed  with  safety.  Personally,  I  believe  this  to  be  3  inches 
(7'5  centimetres),  unless  the  foetal  head  is  abnormally  small.  Pinard,1 
Bar,'-  Zweifel,  Jewett,  Herman,  and  Buist,  as  regards  symphysiotomy, 
are  of  the  same  opinion.  All  of  them  admit  that  a  slightly  lower 
figure  than  3  inches  (7"5  centimetres)  need  not  necessarily  contra- 
indicate  the  operation,  but  in  their  recorded  cases,  with  few  exceptions, 
that  has  been  the  figure.  In  the  cases  in  the  Glasgow  Maternity 
Hospital  the  operation  was  performed  on  two  occasions  with  a  vera  of 
2|  inches  (6*8  centimetres),  and  in  both  there  was  considerable  lacera- 
tion of  the  soft  parts.  In  none  of  our  recent  cases  has  the  vera  been 
less  than  3  inches  (7'5  centimetres).  My  colleagues  and  I  have  come, 
therefore,  to  the  same  conclusions  as  our  British  and  Continental 
confreres  regarding  the  lowest  limit  of  pelvic  deformity  at  which 
symphysiotomy  is  advisable.  Exactly  the  same  figures  apply  to 
pubiotomy. 

With  regard  to  the  upper  limit,  however,  no  definite  figure  can 
be  stated,  for  it  entirely  depends  upon  the  size  and  position  of  the 
child's  head  relative  to  the  pelvis  and  the  favour  in  which  forceps  is 
held  by  the  operator. 

I  have  already  stated,  when  considering  forceps  delivery,  that  with 
a  vera  of  3  inches  (7*5  centimetres)  the  foetal  mortality  in  the  Glasgow 
Maternity  Hospital  with  forceps  was  46  per  cent.  This  mortalit}',  I 
said,  was  so  high  that  I  did  not  consider  one  was  justified  in  trying  to 
deliver  with  forceps  alone.  But,  while  I  make  such  a  statement  with 
all  confidence,  I  cannot,  unfortunately,  make  the  other — that  symphysi- 
otomy or  pubiotomy  should  always  be  employed  with  a  conjugata  vera 
of  3  inches  (7*5  centimetres),  for  the  operation  may  be  a  wise  or 
a  foolish  choice  in  that  degree  of  pelvic  deformity.  What  must 
decide  the  question  is  the  disproportion  between  the  head  and  the 
pelvis.     If  this  is  pronounced,  Cesarean  section  is  indicated  ;  if.  on 

1  Ann.  de  Gyn.,  1896,  1897,  1899. 

2  'Lecons  de  Pathologie  Obstetrical,'  1900. 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY      379 

the  other  hand,  the  disproportion  is  not  very  marked,  then  symphysi- 
otomy or  pubiotomy  may  be  chosen. 

Where  the  pelvis  is  a  little  larger  than  3  inches  (7"5  centimetres), 
I  do  not  believe  that,  in  a  particular  case,  one  can  decide  before 
labour  that  symphysiotomy  or  pubiotomy  is  the  correct  operation. 
One  may  go  the  length  of  thinking  it  possible  that  the  operation  may 
ultimately  be  necessary  ;  but  one  cannot  be  certain,  for  in  such  cases 
labour  may  terminate  spontaneously  or  be  easily  completed  by  forceps. 
If  an  operator  says  to  me  before  or  early  in  labour,  '  This  is  a  case  for 
symphysiotomy  or  pubiotomy,'  I  invariably  think  that  he  does  not 
quite  appreciate  the  refinements  in  the  choice  of  operation  for  pelvic 
deformity  ;  and,  secondly,  that  if,  on  account  of  the  extent  of  the 
pelvic  deformity,  he  has  come  to  the  conclusion  that  one  of  them  is 
necessary,  he  would  be  better  to  choose  Cesarean  section. 

As  far  as  I  have  been  able  to  judge,  they  are  justifiable — I  would 
even  say  indicated — when,  after  the  second  stage  has  been  allowed 
to  go  on  as  long  as  possible,  and  after  two  attempts  at  moderate 
traction,  with  the  patient  in  the  Walcher  position  should  the  pelvis  be 
flat,  it  is  found  that  forceps  just  fails  to  bring  the  child  down  through 
the  pelvis.  The  pelvis  may  be  3^  inches  (8*1  centimetres),  or  even 
3£  inches  (8'7  centimetres),  but  that  should  in  no  way  influence  the 
choice.  It  is,  therefore,  apparent  that  I  would  limit  symphysiotomy 
and  hebosteotomy  to  a  very  few  cases.  As  illustrating  this,  I  may 
mention  that  while  I  have  performed  Cesarean  section  over  eighty 
times,  I  have  only  chosen  symphysiotomy  upon  ten  occasions,  and 
pubiotomy  upon  four  occasions. 

I  am  perfectly  well  aware  that,  although  Olshausen,  Schauta, 
Jewett,  and  English  operators  generally,  favour  a  trial  with  forceps, 
many,  and  amongst  them  the  most  distinguished  obstetricians,  are 
opposed  to  such  practice.  Personally,  I  cannot  conceive  how  it  is 
possible  to  avoid  doing  symphysiotomy  or  pubiotomy  unnecessarily  in 
certain  cases  if  forceps  is  not  tried.  On  several  occasions  I  have  had 
under  my  care  a  patient,  the  size  of  whose  pelvis  and  the  head  of 
whose  fcetus  were  most  carefully  estimated,  prepared  for  possible 
pubiotomy,  and  yet  I  have  delivered  her  with  no  great  difficulty  of 
a  healthy  living  child  with  forceps.  Again,  let  me  repeat,  the  obstet- 
rician of  experience  can  always  say  if  a  head  will  pass  through  a 
pelvis  after  symphysiotomy  or  pubiotomy,  but  he  cannot  always  say 
that  it  will  not  pass  with  a  little  assistance  from  forceps.  Naturally, 
those  who  only  employ  forceps  after  the  head  has  passed  the  con- 
tracted brim,  employ  pubiotomy  much  more  frequently  than  I  do. 
While  I  am  quite  prepared  to  admit  that  up  till  a  few  years  ago  I 
have  delivered  with  forceps  when  I  should  have  performed  symphysi- 


380  OPERATIVE  MIDWIFERY 

otomy  or  pubiotomy,  I  am  equally  certain  that  they  have  had  recourse 
to  these  operations  upon  many  occasions  when  I  would  have  succeeded 
with  forceps  alone. 

'.).  The  Parturient  Canal  must  be  well  Dilated. — It  is  perfectly 
-obvious  that  the  os  must  be  fully  dilated  if  one  intends  extracting  the 
child  immediately  after  dividing  the  symphysis  or  pubis — the  pro- 
cedure most  favoured.  We  shall  have  to  return,  however,  to  this 
subject  later,  when  considering  the  extraction  of  the  child.  But  not 
only  must  the  cervix  be  fully  dilated  :  the  vaginal  canal  must  also  be 
sufficiently  relaxed.  In  multipara  this  invariably  exists.  But  in 
primiparae  it  is  quite  otherwise.  Amongst  my  cases  in  the  Maternity 
Hospital,  both  the  examples  of  severe  lacerations  to  vagina,  vestibule, 
and  urethra  occurred  in  prirnipara?.  This  was  not  because  the  dis- 
proportion between  head  and  pelvis  was  greater  in  them  than  in  the 
multipara?,  but  simply  because  the  soft  parts  had  not  been  previously 
stretched.  When  the  ends  of  the  pubis  are  separated,  and  the  support 
of  the  anterior  pelvic  wall  is  removed,  the  vagina  and  parts  about  the 
vestibule  are  very  liable  to  be  torn  or  burst  during  the  extraction  of 
the  child.  Nearly  all  operators,  therefore,  emphasize  the  special 
danger  to  primiparre,  and  make  it  a  sine  qua  non  that  the  patient  must 
have  already  borne  children. 

To  overcome  the  danger  from  an  undilated  vaginal  canal  in  primi- 
para?,  a  large  colpeurynter  may  be  inserted  into  the  vagina.  Bar  and 
others  speak  very  highly  of  the  benefit  to  be  derived  from  this  pro- 
cedure. Traction  may  be  made  upon  the  colpeurynter  either  by 
pulling  upon  it  from  time  to  time  or  by  attaching  a  weight  to  the 
ond  of  it.  In  the  case  of  prirnipane,  deep  incisions  into  the  lower 
part  of  the  vaginal  wall  and  the  perineum  prevent  lacerations  of  the 
vestibule  and  vagina,  and  may  be  had  recourse  to  if  the  vulvar  orifice 
is  very  narrow. 

Some  operators  have  recommended  the  performance  of  the  opera- 
tion early  in  labour.  That  is  a  mistake,  as  one  cannot  tell  beforehand 
that  a  head  will  not  mould  sufficiently  to  pass  the  brim  without 
division  of  the  symphysis  or  pubis. 

4.  The  Parturient  Canal  must  not  be  Infected. — If  the  patient 
has  been  infected,  or  has  been  presumably  infected,  by  those  in 
attendance,  it  is  undesirable  to  subject  her  to  the  risk  of  symphysi- 
otomy or  pubiotomy — especially  as  in  most  cases  when  the  canal  is 
infected  several  attempts  at  delivery  with  forceps  have  been  made,  and 
the  child's  vitality  has  been  distinctly  reduced.  This,  of  course,  as 
already  indicated,  does  not  apply  to  failure  to  deliver  with  forceps, 
carefully  employed.  What  I  am  opposed  to  is  subjecting  a  woman, 
probably  infected,  to  the  dangers  of  symphysiotomy  or  pubiotomy 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY      381 

when  the  child  has  already  been  much  injured  and  it  is  very  question- 
able if  it  will  survive.  Naturally,  the  only  alternative  in  such  cases  is 
craniotomy. 

Anatomy  of  the  Parts  concerned  in  Symphysiotomy  and 

Pubiotomy. 

Before  proceeding  to  discuss  the  surgical  procedure  in  symphysi- 
otomy and  pubiotomy,  a  knowledge  of  the  anatomy  of  the  parts  is- 


Dorsal  Vein 
of  Clitoris. 


Fibro-cartilagc. 


Subpubic  Ligament. 


\ 


Ischium. 
\ 


y 


Arteries  of  Clitoris. 


Transverse  Perineal. 
Ligament. 


Pudic  Vessels. 


Triangular  Ligament 


Fig.  174. — Dissection  to  show  Anatomy  of  the  Symphysis  Pubis. 


necessary.  The  articulation  between  the  pubic  bones  is  an  amphi- 
arthrodial  joint  formed  by  the  juncture  of  the  two  oval  articular 
surfaces  of  the  ossa  pubis.  This  joint  consists  of  a  disc  of  fibro- 
cartiiage  connecting  the  surfaces  of  the  pubic  bones  in  front,  and 
contains  a  cavity  in  its  centre,  caused  by  the  absorption  of  the 
fibro-cartilage,  and  is  lined  by  synovial  membrane. 

Each  pubic  symphysis  is  covered  by  a  thin  layer  of  hyaline  car- 
tilage, which  is  connected  to  the  bone  by  a  series  of  nipple-like 
processes.     This   cartilage    may   catch   the   knife   of    the    unskilled 


382 


OPERATIVE  MIDWIFERY 


operator,  although  there  is,  in  reality,  ample  room  ;  hence,  pre- 
samably,  is  the  reason  of  incorrect  statements  concerning  hony 
ankylosis  and  the  diihculties  they  may  cause  in  the  operation  of 
dividing  the  joint. 


Fig.  175. — Dee])  Dissection  of  Female  Perineum  to  show  Structures  likely  to  be  injured  in  the 
Operations  of  Symphysiotomy  and  Pubiotomy. 

".  <  'i  us  clitoridis  ;  b,  olitoris  ;  c.  suspensory  ligament  of  clitoris  ;  d,  meatus  urinarius  ;  ■ 

to  clitoris  ;/,  artery  to  cms  clitoridis;  g,  left  cms  divided  and  retracted  to  show#J 
h,  internal  pudic  artery;  i,  vagina;  /,  sphincter  vagina? ;  m,  levator  ani;  h,  anus: 
o,  sphincter  ani  ;  p,  border  of  gluteus  maximus  :  q,  artery  to  lmlb  :  r,  internal  pudic 
artery  more  superficial  than  /<  ;  ••>,  ischium. 

The  stability  of  the  symphysis  depends  less  on  this  fibro-cartilage 
than  on  the  fibrous  investment  which  it  receives  from  the  anterior, 
posterior,    superior    and    inferior    pubic    ligaments.     The   ligament 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY      388 

of  greatest  importance,  anatomically  and  surgically,  is  the  inferior 
or  subpubic  ligament  (Fig.  171).  This  ligament  is  of  considerable 
thickness  and  strength.  It  forms  the  upper  boundary  of  the  pubic 
arch,  and  is  attached  above  to  the  interpubic  disc  and  laterally  to 
the  adjacent  sides  of  the  descending  rami  of  the  pubes.  Its  lower 
border  is  free,  and  is  separated  from  the  triangular  ligament  by  a 
transverse  oval  interval,  through  which  the  dorsal  vein  of  the  clitoris 
passes  backwards  to  the  interior  of  the  pelvis. 

The  arterial  supply  to  the  structures  of  importance  in  the  opera- 
tion of  symphysiotomy  and  pubiotomy  is  derived  chiefly  from  the 


Fig.  176. — Symphysis  Pubis  from  behind,  to  show  Main  Trunks  forming  Venous  Plexus. 

(Farabceuf.) 

internal  pudic  artery.  The  obturator  and  deep  epigastric  arteries 
send  small  twigs  to  the  thickened  periosteum  of  the  symphysis 
pubis. 

Each  crus  clitoridis  receives  a  branch  from  the  internal  pudic 
artery,  while  the  glans  clitoridis  is  supplied  by  its  terminal  branches 
(dorsal  arteries  of  the  clitoris — Fig.  175). 

The  main  source  of  bleeding,  on  which  much  stress  is  laid  by 
some  operators,  is  venous,  chiefly  from  tearing  of  the  loose  unsup- 
ported plexus  of  veins  which  surrounds  the  upper  part  of  urethra  and 
neck  of  bladder — viz.,  the  inferior  vesical  plexus  (Figs.  176  and  177). 
The  dorsal  vein  of  the  clitoris  in  its  course  backwards  to  the  inferior 


884 


OPERATIVE  MlhWIIT.n 


vesical  plexus  is  apt  to  cause  trouble  when  the  clitoris  La  detached,  if 

the  vessel  has  not  been  previously  clamped. 

Another  source  of  hemorrhage,  upon  which  little  stress  has  been 
laid,  is  tearing  of  the  bulbus  vestibuli  and  roof  of  vagina.     The  bulbut 

vestibuli  is  composed  of  minute  convoluted  bloodvessels  held  together 
by  a  very  small  amount  of  connective  tissue — a  particularly  difficult 
tissue  in  which  to  check  haemorrhage.     Its  arterial  supply  is  derived 


Anterior  \V;ill  of  Bladder. 


Inferior  Vesical 
Plexus. 


I  ii  real  Vein  of 
Clitoris  in 
Inferior  Vesi- 
cal Plexus. 


Dorsal  Vein  of  Clitoris. 


Fie.  177.— One  Half  of  Symphysis  Pubis  removed  to  show  Bladder  and  Venous  Plexus. 

(Farabceuf.) 

on  each  side  from  a  branch  (arteria  bulba  vestibuli)  of  the  internal 
pudic.  The  bleeding  from  tearing  of  the  bulba  vacf'nue  is  mainly 
venous,  arising  from  rupture  of  the  large  veins  of  the  vaginal  plexuses, 
which,  in  sympathy  with  the  general  increased  calibre  of  vessels 
during  pregnancy,  have  become  enormously  dilated  and  tortuous. 

Methods  of  Performing-  Symphysiotomy. — Having  briefly  de- 
scribed the  anatonry,  we  must  now  turn  to  the  different  methods  of 
performing  the  operation  of  symphysiotomy.  The  woman  being 
anaesthetized,    the   pubes    shaved,    and   the   parts    about   the   vulva 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY      385 

thoroughly  cleansed,  the  pelvis  should'  be  brought  to  the  edge  of  the 
operating  table  or  couch,  and  the  legs  supported  by  two  assistants. 
Zweifel  allows  the  legs  to  hang  down,  and  if  the  accoucheur  is  short  of 


Fig.  178. — Division  of  Suspensory  Ligament  of  Clitoris.     (Faraboeuf.) 

assistants  it  is  all  right,  for  in  that  position  the  pubic  bones  will  not 
spring  so  widely  apart  as  they  would  do  if  the  legs  lay  abducted. 

As  regards  the  actual  method  of  performing  the  operation,  there 
are  certain  differences  in  detail  in  different  countries.  Let  me  take 
the  French  method  first — the  method  perfected  by  Faraboeuf,  and 
without  doubt  the  most  exact. 

25 


386 


OPERATIVK   MiI)\VIFi:i;V 


An  incision  is  made  over  the  symphysis  of  about  3  inches 
7*5  centimetres)  in  Length,  and  extending  from  about  l'.  inches  above 
the  pubis  to  the  line  which  the  operator  has  made  with  tincture  of 
iodine  to  mark  off  the  lower  limit  of  the  triangular  ligament.  Should 
the  clitoris  be  placed  higher  than  usual,  a  '  lambda'  incision  is  made 
round  it.     The  clitoris  must  then  he  pulled  downwards,  and  its  sus- 


Fig.  179. — Stages   in   the   Division    of  Recti    Abdominis.     (Farabceuf.) 
The  skin  lias  already  been  divided,  and  is  held  apart  by  retractors. 


pensory  ligament  divided  (Fig.  178),  all  bleeding  being  suitably  con- 
trolled. This  being  done,  the  lower  margin  of  the  triangular  ligament 
is  defined.  The  operator  now  turns  to  the  upper  part  of  the  wound, 
and  makes  a  longitudinal  incision  through  the  linea  alba  (Fig.  L791 
It  is  desirable  to  keep  the  incision  longitudinal,  but  if  it  is  not  possible 
to  get  the  fingers  in  through  the  opening,  the  assistant  should  flex 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY      387 

the  legs,  and  the  operator  make  slight  cuts  laterally.  A  finger  and 
then  a  grooved  director  (Fig.  180)  is  pushed  behind  the  puljes  into 
the  so-called  space  of  Retzius,  between  the  bladder  and  the  posterior 


Fig.  180.— Division  of  Symphysis  Pubis.     (Farabceuf.) 


surface  of  the  pubic  bones.  Having  done  this,  the  director  is  with- 
drawn and  introduced  under  the  triangular  ligament  from  below 
upwards.  The  operator  then  cuts  upon  the  director  from  behind 
forwards  with  the  point  of  a  short-bladed  knife  (Fig.  180). 


::ss  OPE  It  ATI  VK   M  1 1  »\V1  l-T.UY 

In  recent  years  the  operation  has  been  much  simplified,  and  the 
following  is  the  method  I  have  always  employed:  Eaving  made  an 
incision  over  the  Bympbysis  pubis,  and  pushed  my  finger  down  behind 
the  joint  as  already  described,  I  divide  the  joint  from  before  hack- 
wards  and  above  downwards  with  a  Btrong  small-bladed  bistoury.  I 
then  divide  the  triangular  ligament,  keening  well  to  the  leftside.  I 
do  not  believe  there  is  much  danger  to  the  urethra  at  this  stage ;  the 
real  danger  to  the  urethra  is  during  the  extraction  of  the  child.  Con- 
sequently, I  do  not  introduce  a  sound  into  the  bladder  and  drag  the 
urethra  over  towards  the  other  side. 

Morisani,  and  Italian  operators  in  general,  make  a  small  incision, 
longitudinal  or  transverse,  above  the  symphysis,  then  push  the  fore- 
finger down  behind  the  pubic  joint,  and  divide  the  latter  from  behind 
forwards  and  from  below  upwards  with  a  special  curved  knife.  There 
are  various  forms  devised  by  Galbiati,  Spinelli,  Novi,  etc. 

Zweifel,  the  great  advocate  of  the  operation  in  Germany,  operates 
in  very  much  the  same  manner  as  the  Italians.  After  a  transverse 
or  longitudinal  incision  over  the  pubes,  he  passes  his  forefinger  behind 
the  joint.  If  there  is  any  difficulty  in  defining  the  joint,  an  assistant 
moves  the  leg.  With  a  probe-pointed  knife  the  joint  is  divided  from 
behind  forwards.  The  triangular  ligament  is  then  exposed,  and  care- 
fully divided  from  above  downwards.  Any  danger  of  injuring  the 
urethra  is  avoided  by  directing  the  urethra  over  to  the  right  with  a 
sound  in  the  bladder. 

Immediately  after  the  division  of  the  joint  and  of  the  triangular 
ligament,  but  only  then,  the  pubic  bones  spring  apart.  Only  once 
have  I  had  any  difficulty  in  dividing  the  joint,  and  that  was  when  it 
was  irregularly  formed.  Such  is  the  experience  of  all  other  operators. 
Ankylosis  of  the  joint  is  practically  unknown.  Zweifel,  Morisani, 
Bar,  and  Pinard  are  all  of  that  opinion.  Irregularities  in  direction 
are  not  infrequent,  and  sometimes  trouble  arises  from  the  operator 
not  noting  the  exact  position  of  the  joint  and  cutting  into  the  fibro- 
cartilage.  A  condition  which  has  occasionally  prevented  a  sufficient 
separation  of  the  pubic  bones  is  an  ankylosis  of  the  sacro-iliac 
joint.  It  is  quite  unnecessary,  therefore,  to  employ  any  instrument 
to  forcibly  separate  the  pubic  joint :  that  can  be  done  b}r  those 
in  charge  abducting  the  legs  according  to  the  instructions  of  the 
operator. 

After  complete  division  of  the  symphysis  pubis,  an  important  point 
for  consideration  now  arises  :  Should  the  child  be  extracted  with  forceps 
immediately  after  the  division  of  the  symphysis,  or  should  time  be 
given  the  natural  forces  to  bring  about  the  expulsion '?  Just  as  might 
be  expected,  seeing  that  a  good  deal  can  be  said  for  both  courses, 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY      389 

each  has  its  supporters,  but  the  majority  of  operators  now  favour 
immediate  delivery  by  forceps  or  version.  In  the  Glasgow  Maternity 
Hospital  the  delivery  has  always  been  completed  with  forceps. 
Without  doubt,  artificial  delivery  increases  the  risks  of  laceration  of 
the  soft  parts ;  but  if  the  patient  is  a  multipara,  and  the  case  carefully 
selected,  careful  extraction  should  not  be  followed  by  much  injury  to 
vagina  or  urethra. 

If  the  case  is  left  to  Nature,  a  temporary  dressing  is  put  over  the 
wound,  and  a  bandage  applied  round  the  pelvis  so  as  to  support  it. 
If  such  a  course  is  followed  delay  in  expulsion  of  the  head  is  not  in- 
frequent. If  not  caused  by  simple  uterine  inertia,  it  is  generally  the 
result  of  the  head  continuing  to  lie  with  its  long  axis  in  the  transverse 
diameter  of  the  pelvis.  This  arises  from  widening  of  the  pelvis  and 
lessening  of  the  resistance  of  the  pelvic  floor. 

If  artificial  extraction  is  proceeded  with,  the  blades  of  the  forceps 
are  carefully  applied  and  slow  and  steady  traction  made.  When 
previous  attempts  to  deliver  with  forceps  have  been  made,  it  is  ad- 
visable to  leave  the  instrument  loosely  applied  to  the  head  while  the 
symphysis  is  divided. 

The  pelvis  during  extraction  must  be  supported.  This  is  best 
done  by  an  assistant  on  either  side  holding  the  leg  in  one  hand  and 
pressing  on  the  trochanter  with  the  other.  Should  the  operator  have 
insufficient  assistance,  a  binder  should  be  applied  round  the  pelvis 
and  the  legs  allowed  to  hang  down.  It  is  very  important  that  the 
pelvis  should  be  properly  supported,  and  that  the  amount  of  separa- 
tion should  be  controlled  ;  and,  not  only  that,  but  the  separation 
should  be  equal,  otherwise  there  will  be  a  greater  strain  thrown  upon 
one  sacro- iliac  joint  than  upon  the  other. 

In  the  Glasgow  Maternity  Hospital  we  have  very  generally  placed 
the  patient  in  the  Walcher  position,  and  without  any  harm  resulting. 
Some  operators,  however,  are  opposed  to  such  a  procedure,  for  they 
believe  that  if  there  is  any  difficulty  in  extracting  the  child  the  danger 
of  injuring  the  sacro-iliac  joints  will  be  increased. 

It  is,  I  take  it,  quite  unnecessary  to  discuss  another  method  of 
delivery — viz.,  version — for  almost  no  one  is  in  favour  of  it  in  this 
country.  Several  French  operators,  however,  recommend  it.  Bar 
discusses  the  method,  and,  although  his  results  are  quite  as  good 
with  it  as  with  forceps,  he  gives  it  very  little  support. 

After  the  delivery  of  the  child  there  is  sometimes  fairly  free  bleed- 
ing, which  should  be  controlled  by  packing  some  gauze  down  behind 
the  pubes  and  pressing  down  the  uterus  from  above.  It  is  futile  to 
try  and  catch  the  bleeding-points. 

The  third  stage  should  be  managed  in  the  same  way  as  in  a  normal 


890  OPERATIVE  MIDWIFEM 

labour.  If  desired,  a  temporary  binder  may  be  applied  round  the 
pelvis.  Some  prefer  to  give  five  or  seven  minutes  for  placental 
separation,  and  then  express  or  remove  the  placenta  manually. 

There  now  remains  only  the  stitching  of  the  wound  to  complete 
the  operation.  Before  describing  (his,  however,  there  is  one  question 
which  must  he  considered,  and  that  is,  Should  the  space  of  Retziue 
be  drained?  "Without  douht,  in  many  cases,  hlood  collects  there,  and, 
not  obtaining  a  free  exit,  is  a  source  of  danger  should  it  become  in- 
fected. Zweif  el  is  a  strong  advocate  of  draining;  Pinard  also  approves 
of  it,  but  Bar  looks  upon  it  unfavourably.  Drainage  from  above  is 
unsatisfactory.  I  have  found  Zweifel's  suggestion  x  of  draining 
through  an  opening  in  the  left  labium  minor  very  useful.  I  employ 
a  loose  packing  of  gauze  and  push  it  well  down  behind  the  joint :  the 
end  of  the  gauze  I  pull  out  through  an  opening  in  the  left  labium. 
If,  however,  there  happens  to  he  any  wound  into  the  vagina,  J  drain 
through  it. 

In  closing  the  joint,  pegging  or  wiring  the  bones  is  quite  un- 
necessary ;  stitching  of  the  wound  as  shown  (Fig.  ]H1)  is  all  that  is 
required  to  obtain  satisfactory  union.  Personally,  I  employ  three 
chromicized  catgut  sutures  for  the  periosteum,  ordinary  catgut  for  the 
fascia,  and  silkworm  for  the  skin.  Before  introducing  the  sutures, 
the  edges  of  the  pubic  bones  must  he  brought  exactly  together,  and 
for  holding  them  together  the  forceps  of  Farabeeuf  (Fig.  181)  are  very 
useful.  Failing  that  instrument,  a  strong,  single-pronged  vulsellum 
forceps  may  be  employed.  I  find,  however,  that  no  special  instru- 
ment is  necessary  if  the  edges  of  the  bones  are  brought  well  together 
by  the  assistants.  The  stitching  is  very  simple.  In  bringing  the 
edges  together,  care  must  be  taken  that  the  bladder  and  gauze 
packing,  which  is  left  in  to  drain  the  lietzius  pouch,  are  not  caught 
between  them.  On  one  occasion  the  latter  accident  happened  to 
me,  and  I  had  great  difficulty  in  getting  the  gauze  out  of  the 
wound. 

Should  post-partum  haemorrhage  occur  from  the  uterus,  it  is  to  be 
treated  by  the  ordinary  means ;  personally,  I  have  never  required  to- 
pack  the  uterus,  having  always  found  that  ergot  and  hot  douching 
controlled  the  bleeding. 

The  after-treatment  of  cases  of  symphysiotomy  is  exceedingly 
troublesome ;  indeed,  that  to  my  mind  is  the  great  objection  to  the 
operation.  The  following  is  the  method  employed  in  the  Glasgow 
Maternity  Hospital :  A  simple  dressing  is  applied  over  the  wound,  and 
kept  in  position  by  bands  of  adhesive  plaster  which  are  applied  right 
round  the  pelvis.     A  large  pad  of  absorbent  cotton  is  then  plaa  d 

1  Zent.f.  Gyn.,  1902,  No.  18,  p.  821. 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY      891 

over  the  part,  and  a  firm  binder  applied  round  the  pelvis.  The  patient 
is  then  put  to  bed,  and  two  long  sand-bags  are  placed  and  maintained 
in  position  against  the  pelvis  and  thighs. 

In  order  to  facilitate  the  sponging  of  the  vulva  and  the  toilet  of 
bowel  and  bladder,  the  charge  Sister  of  the  hospital  devised  a  mattress 
which  consists  of  three  portions,  the  middle  part  being  a  narrow  strip 
which  can  be  easily  slipped  out.  This  allows  the  nurse  to  reach  the 
parts  very  conveniently  without  disturbing  the  patient. 

The  gauze  drain  in  the  Eetzius  pouch  is  removed  in  twenty-four 
hours,  and  replaced  or  not  as  is  deemed  advisable.     The  bowels  are 


Fig.  181. — Uniting  divided  Symphysis. 
Figure  on  the  right  shows  Farabceuf's  forceps  for  coapting  the  severed  joint.     (Farabceuf.) 


moved  on  the  third  day,  and  then  every  second  day.  The  stitches  are 
removed  on  the  twelfth  day,  and  the  patient  is  allowed  up  about  the 
twenty-fourth  day. 

I  need  hardly  say  that,  should  any  lacerations  occur  to  the  soft 
parts  as  the  result  of  the  operation,  these  should  be  carefully  repaired. 
Any  tearing  of  the  vagina  should  be  stitched,  and,  above  all,  one 
should  make  sure  that  every  care  is  taken  in  making  good  any  injury 
to  the  urethra. 

The  Subcutaneous  Method  of  Performing'  the  Operation. — As 
an  alternative  to  the  methods  of  performing  symphysiotomy  already 
described,  several  operators  have  recommended  subcutaneous  division 
o£  the  symphysis.     The  Americans,  and  I  think  with  right,  claim  this 


892 


OPERATIVE  MlhWll  i:i;Y 


as  their  method,  for  undoubtedly  Ayr.-  deserve.-  the  credit  of  having 
brought  ii    prominently  forward.      In   England   Eerman  and  Buist 

have  each  detailed  series  of  cases  in  which  the  operation  was  easilv 
and  successfully  carried  out. 

\yres'1  method  is  described  by  Edgar2  as  follows: 

'The  left  index  finger  is  introduced  within  the  vagina,  and  held 
against^the  posterior  aspect  of  the  joint  (Fig.  182).  A  narrow  teno- 
tomy knife  is  then  passed  up  to  a  point  within  \  inch  of  the  summit 
of  the  joint  beneath  the  overlaying  soft  tissues.     A  probe-pointed 

bistoury  is  then  substituted  for  the  tenotomy  knife,  and  carried  to  the 
top  of  the  joint,  where  it  meets  the  index  finger:  it  is  then  carried 
downwards  through  the  joint  until   the  latter  is  felt  by  the    index 


Fig.  182. — Subcutaneous  Symphysiotomy-  Ayres'  Method.     (Edgar.) 


finger  behind  to  give  way.  An  assistant  now  presses  a  small  gauze 
compress  against  the  incision  beneath  the  clitoris.  If  possible,  the 
child  is  then  delivered  with  forceps.' 

Herman's  method3  is  even  simpler  :  '  Take  the  tenotomy  knife  and 
press  its  point  through  the  mucous  membrane  opposite  the  middle  of 
the  symphysis'pubis.  It  will  easily  penetrate  the  symphysis.  If  you 
have  not  hit  the  middle  line  and  the  point  impinges  on  bone,  the 
difference  of  resistance  will  inform  you  of  the  fact ;  if  so,  shift  the 
point  a  little  to  the  right  or  left,  and  it  will  come  upon  the  symphysis. 
When  the  knife  has  penetrated  the  symphysis,  cut  downwards  until 
you  have  reached  and  divided  the  ligamentum  arcuatum.  Then  turn 
the  blade  so  that  the  cutting  edge  is  upwards,  and  divide  the  rest  of 
the  symphysis.     There  may  be  a  little  difficulty  in  dividing  the  last 

1  Amer.  Journ.  Obst.,  July,  1897.  -  '  Text-book,'  190:$,  p.  969. 

3  '  Difficult  Labour,'  1910,  p.  467. 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY      3«)3 

ligamentous  fibres  at  the  top  and  lower  part  of  the  symphysis,  because 
there  is  a  little  tendency  for  the  knife  to  push  these  fibres  before  it, 
instead  of  cutting  quickly  through  them.  You  will  overcome  this 
tendency  by  pressing,  with  the  finger  applied  externally,  these  fibres 
against  the  knife.  When  you  have  divided  all  the  fibres  which  unite 
the  two  pubic  bones,  they  will,  at  once,  spring  about  \  inch  apart ; 
then  seize  the  foetal  head  with  forceps  and  deliver.' 

Personally,  I  can  offer  no  opinion  about  either  of  these  methods. 
Buist1  and  Herman,2  however,  speak  very  highly  of  the  operation,  and 
many  successful  cases  so  treated  have  been  recorded  in  this  country 
and  in  America. 

Zweifel  has  written3  in  support  of  subcutaneous  symphysiotomy. 
His  method  can  hardly  be  described  as  subcutaneous,  as  that  term  is 
generally  understood.  An  opening  is  made  above  and  below  the  pubis, 
the  bladder  is  pushed  away,  and  a  needle  is  passed  behind  the  joint. 
The  saw  is  then  pulled  through,  and  the  joint  divided  by  means  of  it. 
Zweifel  makes  no  reference  to  the  methods  just  described,  although 
they  may  be  much  more  correctly  termed  subcutaneous,  and  have 
been  known  and  practised  for  years  in  this  country  and  America. 

Prognosis. 

The  results  from  symphysiotomy  in  the  hands  of  those  who  have 
had  experience  of  the  operation  are  highly  satisfactory ;  indeed,  I  can- 
not understand  how  anyone  would  wish  to  do  away  with  the  operation. 

I  am  well  aware  that  some  teachers  of  obstetrics  are  opposed  to 
the  operation.  In  not  a  few  cases,  however,  their  opposition  is 
negligible,  for  they  have  had  absolutely  no  experience  of  it.  Some 
time  ago  I  heard  a  prominent  teacher  of  obstetrics  condemn  the  opera- 
tion— to  my  certain  knowledge  he  had  never  performed  the  operation. 
Without  doubt  there  have  been  cases  of  disaster,  but  many  of  these 
•could  have  been  avoided  if  greater  care  had  been  taken  in  selecting 
the  cases.  If  the  obstetric  surgeon  thoroughly  understands  what  he 
has  to  do  and  chooses  his  cases  carefully,  the  operation  performed 
upon  patients  brought  to  hospital  in  labour  will  be  followed  by  much 
■better  results  than  Cesarean  section.  I  challenge  any  opponent  of 
symphysiotomy  to  refute  that  statement.  I  do  not  consider,  however, 
that  the  operation  is  suited  for  domestic  practice.  The  general 
practitioner,  unless  he  has  had  very  special  training  in  obstetrics,  does 
better  to  choose  Cesarean  section  or  craniotomy. 

1  Trans.  Edin.  Obst.  Soc,  vol.  xxvii.,  p.  112. 

2  Trans.  Lond.  Obst.  Soc,  1900,  vol.  xlii.,  p.  282. 

3  Zent.f.  Gyn.,  1906,  p.  737. 


394 


OPERATIVE  MIDWIFERY 


I  give  here  a  table,  compiled  a  year  or  two  ago,  showing  the 
maternal  and  foetal  mortality  <>f  ;i  number  of  the  advocates  of 
symphysiotomy. 

Table  of  Symphysiotomy  ('asks. 


Bar      

lot  .1  Cases. 

28 

Maternal  I  ■• 

Postal  i>.  ttba. 

6 

0 

l'ii  1.1  id 

100 

12 

12 

Moiisuni 

55 

2 

8 

Zweifel 

/  52  (open) 
\  12  (subcu- 
taneous) 

8 

0 

I 
0 

Herman 

K 

0 

0 

Jewett... 

8 

1 

1 

Buist   ... 

8 

0 

2 

Munro  Kerr   ... 

9 

0 

0 

The  mortality  is  obviously  most  satisfactory,  but  what  about  the 
morbidity?     Let  us  consider  this  aspect  of  the  subject  in  some  detail. 

The  dangers  to  the  patient  are  :  (a)  Injuries  to  the  sacro-iliac  and 
pubic  joints,  and  resulting  interference  with  locomotion  ;  (b)  severe 
haemorrhage  from  laceration  of  the  parts  in  front  and  behind  the 
symphysis ;  (c)  injuries  to  urethra  and  bladder ;  (d)  septic  infection. 
The  injuries  to  the  sacro-iliac  joint  result  from  too  great  separation 
of  the  pubic  bones,  for,  although  the  ossa  innominata  may  be  com- 
pared to  two  folding  doors  whose  hinges  are  the  sacro-iliac  joints, 
these  hinges  permit  of  only  a  very  limited  movement.  As  might  be 
expected,  it  is  the  superior  and  anterior  ligaments  of  the  sacro-iliac 
joint  which  are  specially  put  on  the  stretch  :  the  strong  posterior  sup- 
ports escape  almost  entirely.  This  is  extremely  fortunate,  and  explains 
why  it  is  that  disturbance  of  locomotion  is  so  very  infrequent. 

Sandstein  states  that  in  the  cadavers  experimented  upon,  in 
44  per  cent,  the  rupture  of  the  anterior  ligaments  began  below  6  centi- 
metres of  pubic  separation,  while  in  ;>6  per  cent,  it  began  above  that 
point.  In  two  it  only  began  at  8  centimetres,  and  in  one  not  even  at 
8  centimetres.  These  observations  of  Sandstein  are,  on  the  whole,  in 
agreement  with  those  of  others,  although  2  or  3  centimetres  of 
separation  has  occasionally  been  found  to  be  sufficient  to  produce 
injury  to  the  sacro-iliac  ligaments.  The  extreme  limit  of  safe  pubic 
separation  is  generally  stated  to  be  7  centimetres,  but  personally  I 
agree  with  Morisani,  Pinard,  Bar,  Zweifel,  and  others,  that  it  is 
inadvisable  to  exceed  6  centimetres.  The  injuries  result  from  exceed- 
ing this  limit,  or  from  allowing  one  side  to  be  more  separated  than 
the  other.     In  those  who  survive  the  operation,  one  can  only  judge  of 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY     395 

injury  to  the  joint  by  disturbance  of  locomotion  or  pains  in  the  joints. 
Doubtless,  if  one  could  examine  the  sacro-iliac  joint  in  all  cases,  one 
would  find  rupture  of  part  of  the  ligaments  in  not  a  few,  for  it  has 
been  noted  at  several  autopsies  of  cases  which  have  died  shortly  after 
operation.  The  fact,  however,  remains  that  few  patients  have  their 
locomotion  disturbed.  Pain  they  sometimes  complain  of  for  a  few 
days  after  the  operation,  but  our  experience  is  in  agreement  with 
Bar's,  that  such  pain  is  almost  always  transitory.  Suppuration  of 
the  joint,  observed  in  one  or  two  cases,  has  only  occurred  where  there 
was  general  septic  infection. 

There  is  no  permanent  injury  done  to  the  pubic  joint.  Faraboeuf, 
Bar,  and  others,  by  means  of  X  rays,  have  been  able  to  demonstrate 
that  there  is,  as  a  rule,  a  permanent  separation  between  the  bones. 
Even  without  the  aid  of  X  rays,  one  can  in  many  cases,  with  the 
fingers  in  the  vagina,  make  out  a  distinct  separation  between  them. 
In  my  cases  the  separation  that  persisted  has  been  very  slight,  due, 
I  have  no  doubt,  to  careful  nursing.  But  even  although  a  little 
persists,  it  is  of  no  great  moment,  for  there  is  very  little  disturbance 
of  locomotion,  provided  the  sacro-iliac  joints  are  not  seriously  injured. 
Nor  is  this  to  be  wondered  at,  for  in  cases  of  split  pelvis  there  is  no 
great  difficulty  in  walking. 

Disturbances  of  locomotion  following  symphysiotomy  are  always- 
referred  to  by  the  general  medical  public,  and  believed  by  them  to  be 
frequent.  That,  however,  is  an  extremely  erroneous  idea ;  not  one  of 
my  patients  has  had  her  locomotion  impaired  in  the  slightest  degree. 
I  am  quite  convinced  that  the  disturbance  has  been  grossly  exaggerated. 
Without  doubt,  defect  in  walking  has  occasionally  followed,  but  such 
cases  are  extremely  rare,  as  the  results  of  Morisani,  Pinard,  Barr 
Zweifel,  Jewett,  Herman,  Buist,  etc.,  show. 

More  serious,  and  infinitely  more  frequent,  are  injuries  to  the  soft 
parts,  especially  to  the  bladder,  urethra,  and  vestibule.  The  worst 
bleeding  arises  from  tearing  of  the  corpora  cavernosa  and  the  venous 
plexuses  behind  and  in  front  of  the  symphysis.  In  cases  where  there 
exists  a  varicose  condition  of  the  veins  underneath  the  integument  in 
front,  haemorrhage  is  naturally  liable  to  occur  when  dividing  the  skin  : 
such  bleeding,  however,  is  very  easily  controlled  by  the  ordinary  means. 
The  bleeding,  however,  which  occurs  after  division  of  the  joint,  from 
tearing  of  the  vascular  tissue  behind  and  to  the  side,  is  often  very 
profuse.  It  can  only  be  arrested  by  plugging  with  gauze,  and  by 
applying  firm  pressure  on  the  uterus  from  above.  Undoubtedly 
Zweifel  is  correct,  that  excessive  haemorrhage  is,  as  a  rule,  the  result 
of  faulty  technique,  although,  as  I  have  already  remarked,  not  so 
much  in  dividing  the  tissues  as  in  extracting  the  child. 


896  OPERATIVE   MIDWIFERY 

So  far  I  have  escaped  Injuring  the  bladder.  Morisani  rathe] 
makes  light  of  the  accident,  as  he  has  never  Been  it  occur:  Bar. 
likewise,  has  not  observed  it.  Pinard,  however,  mentions  it  as  having 
happened  in  two  of  his  hundred  cases,  and  Zweifel  also  has  had 
experience  of  it.  In  one  of  Pinard's  cases  the  injury  was  very  exten- 
sive, and  followed  a  difficult  extraction  of  the  child  with  forceps. 

Very  much  more  frequent  are  injuries  to  the  urethra.  In  one  of 
my  cases  the  urethra  was  torn  completely  from  the  surrounding 
tissues,  and  in  the  other  it  was  split  almost  up  to  the  bladder.  In 
the  former  case  the  tissues  were  brought  together  round  it,  and 
perfect  union  resulted:  hut  in  the  other  the  stitched  urethra  did  not 
heal,  and  the  patient  left  the  hospital  with  practically  no  urethra. 
She  had,  however,  almost  complete  control  of  the  bladder,  except 
when  she  strained,  coughed,  or  sneezed.  All  operators  have  bad 
experience  of  injuries  to  the  urethra:  still,  Pinard,  Varnier,  Zweifel, 
and  Bar  have  had  singularly  few  cases.  Varnier  says,  '  One  ought  tc 
be  able  to  prevent  these  injuries  by  perfecting  the  extraction.'1  I 
entirely  agree  with  him.  Both  my  cases  were  primiparae,  and  I 
believe  the  lacerations  might  have  been  prevented  by  incising  the 
vulvar  orifice. 

Symphysiotomy  Repeated. — I  have  on  one  occasion  performed 
the  operation  twice  upon  the  same  patient,  but  with  a  very  highly 
unsatisfactory  result.  I  divided  the  symphysis  pubis,  but  could  not 
get  any  separation  of  the  bones,  because  there  was  a  firm  mass  of 
tissue  behind  uniting  the  bladder  to  the  posterior  surface  of  the  joint. 
Applying  forceps  with  the  patient  in  the  Walcher  position,  1  extracted 
the  child  with  a  little  difficulty.  During  the  extraction  my  assistants 
kept  up  pressure  upon  the  sides  of  the  pelvis,  and  the  pubic  bones 
separated  only  about  2  centimetres  (f  inch).  I  feared  the  bladder 
might  be  torn.  The  mother  escaped  without  injury,  but  the  child  was 
not  so  fortunate.  There  was  a  deep  indentation  over  the  frontal  bone, 
with  evulsion  of  the  eye.  The  indentation  I  corrected  by  compression 
{Chapter  XXXVII.)  ;  the  eye,  unfortunately,  had  to  be  removed. 

Both  Bar  and  Pinard  refer  to  similar  difficulties  as  I  experienced. 
Bar,  in  one  of  his  cases,  removed  the  cicatricial  tissue  after  dividing 
the  joint.  Nor  is  it  to  be  wondered  at  that  it  should  be  so  when  the 
ordinary  method  is  employed,  for  there  is  bound  to  form  a  very  firm 
•cicatrix.  Buist  and  Herman  have  not  experienced  any  difficulty  in 
the  cases  in  which  they  employed  the  subcutaneous  method. 

An  important  question  arises  at  this  stage:  How  far  is  the  pelvis 
permanently  enlarged  by  symphysiotomy  ?     It  is  generally  stated  that 

1  Corn/pies  rendu8  des  XII  Congria  International  de  Medecin,  Moscow,  L897. 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY      397 


it  is  permanently  enlarged.  This  conclusion  is  come  to  because,  in 
quite  a  number  of  cases,  subsequent  labours  have  terminated  spon- 
taneously or  with  only  a  slight  assistance  with  forceps.  Such 
reasoning  is  apt  to  be  misleading.  Without  doubt  the  pelvis  is 
increased  ;  skiagrams  of  cases  where  the  symphysis  has  been  divided 
show  a  separation  of  the  bones  and  a  distinct  bridge  of  fibrous  tissue, 
but  the  increase  is  infinitesimal  unless  there  is  a  great  permanent 
separation  of  the  divided  ends.  There  is  practically  no  '  give '  in  the 
fibrous  tissue.  The  real  explanation  why  subsequent  labours  terminate 
without  much  difficulty  is,  in  all  probability,  because  the  vagina  has 
been  previously  dilated,  the  size,  shape  and  consistency,  or  position 
of  the  foetal  head  is  more  favourable,  and  the  head  has  been  given 
more  time  to  mould.  I  do  not  believe  that  the  pelvis  is  permanently 
enlarged  to  any  practical  extent  after  symphysiotomy.     The  bearing 


Fig.  183. — Fiith's  Flastic  Operation  for  permanently  enlarging  the  Pelvic  Girdle. 


of  this  is  that  one  must  be  prepared  to  repeat  symphysiotomy,  or 
have  recourse  to  some  other  operation,  at  subsequent  labours. 

Several  plastic  operations  have  been  suggested  for  permanently 
enlarging  the  bony  pelvis,  but  they  have  not  proved  of  any  practical 
value.  Fiith's  suggestion1  is  probably  the  best.  He  has  performed 
the  operation  successfully  several  times,  and  Varnier  referred  to  a 
case  at  the  International  Congress  at  Moscow  in  1897.  The  operation 
consists  in  removing  an  anterior  layer  of  the  pubic  bones  and  joint, 
then  dividing  the  joint  posteriorly  and  placing  the  separated  anterior 
layer  between.  It  will  be  readily  understood  from  the  illustration 
(Fig.  183).  Quite  recently  this  same  author  has  suggested  the  trans- 
planting of  the  xiphoid  cartilage  between  the  ends  of  the  bones.'2  This 
subject  of  plastic  operations  was  fully  discussed  and  severely  criticized 
by  Varnier  years  ago  in  connexion  with  a  paper  by  Phenomenon0  and 
Kotchckoff.3  It  has  very  recently  been  considered  again  by  Klien4  in 
connexion  with  a  very  wild  method  suggested  by  Crede.5 

1  Monat.f.  Geb.  u.  Gyn.,  1896,  vol.  iii.,  p.  491. 

2  Zent.f.  Gyn.,  1907,  p.  692.  3  Ann.  de  Gyn.,  1894. 
4  Zent.f.  Gyn.,  1906,  p.  846.  5  Ibid.,  1906,  p.  617. 


898 


oI'KHativk  Mii'Wii  t.ky 


Pubiotomy,  Hebotomy  (Hebosteotomy). 

Within  the  last  few  years  much  baa  been  written,  especially  in 
the  Italian  and  German  obstetric  journals,  regarding  the  enlargement 
of  the  pelvis  by  dividing  the  pubic  hone  instead  of  the  symphysis. 
Bonardi,   Van  der  Velde,  Gigli,    Doderlein,  and    Bumm   have   been 

especially  prominent  in  advocating  this  method.  The  credit,  however, 
of  first  recommending  it,  as  an  alternative  to  symphysiotomy,  is 
undoubtedly  due  to  Stol/.,1  who  described  in  1814  the  operation  which 
is  being  practised  to-day,  even  to  the  use  of  a  saw.     Nearly  twenty 


Fig.  184. — The  Symphysis  Pubis  bom  the  Front. 

The  lines  A  and  B  represent  the  directions  in  which  the  pubes  may  be  divided  in  the 
operation  of  pubiotomy.  A  is  the  direction  recommended  by  Van  der  Velde  ;  15.  that 
recommended  by  Gigli. 

years  ago  Sir  William  Macewen,  of  Glasgow,  made  a  communication 
on  the  subject  at  the  International  Congress  in  Berlin. 

But  the  symphysis  is  not  a  joint  in  the  ordinary  sense,  nor  is  it, 
when  opened,  subject  to  the  same  dangers  as,  say,  the  knee-joint; 
consequently,  the  claim  that  there  is  greater  danger  in  opening  and 
dividing  the  symphysis  than  in  dividing  the  pubic  bone  is  purely 
theoretical. 

As  far  as  one  can  judge  there  is  slightly  less  risk  of  injuring  the 
urethra,  but  Zweifel  and  Doderlein  indicated  at  the  Deutschen 
Gyniikologen  Kongress  in  Dresden  in  1!I07,2  that  the  bladder  is  not 

1  Fasbender,  'Geschichte  der  Geburtschiilfe,'  1906,  p.  872. 

2  Zent.f.  Gyn.,  L907,  No.  24. 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY      399 

a  little  endangered,  especially  if  the  subcutaneous  method  of  Bumm 
is  employed.  It  has  always  been  admitted  that  the  chief  danger  to 
the  urethra,  bladder,  and  vagina  arises  during  the  extraction  of  the 
child,  so  that  to  justify  the  choice  of  pubiotomy  it  must  be  proved 
that  the  danger  of  injuring  these  structures  is  really  less  during 
extraction.  liar1  doubts  it,  but  Baisch-  thinks  otherwise.  On 
anatomical  grounds  there  should  be  more  bleeding  with  pubiotomy, 
unless  the  corpus  cavernosum  is  carefully  stripped  off  and  pushed 
well  out  of  the  way.  As  a  matter  of  fact,  Zweifel  has  abandoned 
pubiotomy  because  of  this  hemorrhage.     This  bleeding  may  not  only 


.M 


Fig.  185. — Pubiotomy,  after  the  Method  recommended  by  Doderlein. 


occur  at  the  time  of  operation,  but  a  slow  oozing  may  continue,  with 
the  formation  of  a  hematoma. 

Several  important  communications  have  been  made  regarding  the 
primary  and  permanent  enlargement  of  the  pelvis  resulting  from  the 
respective  operations.  One  of  the  most  interesting  is  by  Sellheim,3 
who  has  gone  into  the  subject  most  carefully. 

He  states  :  '  Hebotomy  and  symphysiotomy  bring  about  the  same 
alterations  in  the  birth  canal.'  It  would  appear  also  with  both  there 
is  a  slight  permanent  increase  in  the  pelvic  capacity.     After  symphy- 

1  '  L'Obstetrique,'  1905,  p.  245. 

2  '  Keforinen  in  der  Therapie  des  engen  Becken,'  Leipzig,  1907,  p.  181. 

3  Monat.f.  Geb.  u.  Gyn.,  1906,  Bd.  xxiii.,  p.  362. 


10(1 


OPERATIVE  MIDW  l!'Kl;Y 


siotomy  the  union  is  naturally  fibrous,  hut  after  pubiotomy  bony. 

lloeheisen1  has  recorded  sixteen  eases  operated  on  in  Bumm'a  Klinik  ; 
skiagraphs  accompany  the  paper.  Me  states  that  after  a  few  months 
bony  union  is  always  present. 

Having  followed  very  carefully  the  discussions  in  this  and  other 
countries  regarding  symphysiotomy  and  pubiotomy,  I  am  inclined  to 
think  that,  if  anything,  puhiotomy  is  the  safer  operation  :  but  it  is 
only  very  slightly  safer,  and  so  I  can  quite  understand  the  attitude  of 


Fig.  186. — Subcutaneous  Pubiotomy. 


Herman,  who  stated  recently  that  he  was  still  a  supporter  of  sym- 
physiotomy. 

In  performing  pubiotomy,  division  of  the  hone  is  best  made  with 
a  Gigli  saw  (Fig.  185),  the  direction  being  either  as  Van  der  Yelde  or 
Gigli  has  suggested  (Fig.  184).  Van  der  Yelde's  incision  certainly  is 
less  likely  to  cause  injury  to  the  internal  pudic  artery  and  the  corpus 
cavernosum.  It  is  not  possible  to  avoid  the  latter  altogether,  however, 
unless  it  is  first  separated  and  pushed  aside.  An  objection  to  adopt- 
ing Gigli's  line  is,  as  I  found  on  one  occasion,  that  if  the  symphysis 
is  oblique  one  may  come  right  down  upon  it.     Doderlein  had  a  similar 

1  Archivf.  Gyn.,  1906.  Bd.  lxxx..  Heft  1.,  p.  99. 


THE  ENLARGEMENT  OF  THE  PELVIC  CAPACITY      401 

experience.1  There  is  a  great  variety  of  carriers  for  the  saw,  and 
some  operators  pass  them  from  above  downwards  and  some  from 
below  upwards.  Undoubtedly  the  safest  plan  is  to  make  an  incision 
a  little  external  to  the  pubic  spine,  and  introduce  the  forefinger  behind 
the  pubis  and  push  the  bladder  aside.  This  method  of  J)6derlein 
(Fig.  185)  cannot,  of  course,  be  termed  subcutaneous.  Bumm's 
method,  however,  is  subcutaneous  (Fig.  18G).  He  passes  a  curved 
saw-carrier  close  under  the  pubic  arch,  entering  it  between  the  larger 


Fig.   187. — Dividing  Pubes  with  Saw. 

and  lesser  labia.  The  clitoris  and  labium  minor  are  pulled  over  to 
the  other  side.  The  carrier  is  then  pushed  round  the  bone,  the  point 
of  the  instrument  being  kept  hard  against  the  bone.  It  is  brought 
out  close  by  the  inner  margin  of  the  spine  of  the  pubis.  The  saw  is 
then  pulled  through,  and  the  bone  divided  (Fig.  187).  The  child  is 
then  delivered  artificially  by  forceps  or  version.  After  the  delivery 
is  completed,  and  all  blood  has  been  squeezed  out  of  the  wound,  the 
small  openings  in  the  skin  above  and  below  are  closed  with  stitches. 


1  Archivf.  Gyn.,  1904,  Bd.  lxxii.,  p.  287. 


26 


402  OPERATIVE  MIDWIFERY 

A  dressing  is  then  applied  over  the  wounds  and  the  pelvis,  supported 
hy  a  binder.  It  has  been  found  in  recent  years  that  a  moderate 
support  of  the  pelvis  is  all  that  is  necessary. 

A  still  more  lateral  division  of  the  pelvis  was  carried  out  by  Faralm  iuf 
and  Pinard !  in  a  case  of  obliquely  contracted  pelvis.  The  pubes 
and  ischium  were  divided  about  4  centimetres  from  the  middle  line. 
This  operation  has  been  termed  '  ischio-pubiotomy.'  The  result  was 
most  satisfactory.  The  child  was  saved,  and  the  mother  made  an 
excellent  recovery.  Bony  union  is  reported  to  have  followed.  A 
similar  operation  was  suggested  by  Aitken  -  of  Edinburgh  in  1784. 

Mortality  and  Morbidity  of  Pubiotomy. — During  the  last  two 
years  I  have  performed  pubiotomy  four  times.  In  one  case  death 
followed  from  sepsis,  and  in  another  the  wound  became  infected,  while 
in  the  other  two  the  patients  made  perfectly  satisfactory  recoveries. 
In  the  fatal  case  the  woman  had  been  in  labour  and  the  membranes 
had  been  ruptured  long  before  she  was  admitted  to  hospital,  and  it  was 
rather  against  my  better  judgment  that  I  performed  the  operation. 
Craniotomy  was  the  operation  I  should  have  chosen. 

As  regards  the  results  in  Germany,  where  pubiotomy  is  most 
favoured,  Hammerschlag  in  his  recent  work,3  states  that  in  77  cases 
operated  on  by  the  open  method,  the  mortality  was  10*4  per  cent., 
while  in  700  cases  operated  on  by  the  subcutaneous  method  (Bumm 
and  Doderlein),  it  was  4*4  per  cent.  The  total  mortality  was  9  per 
cent.  If  the  reader  refers  back  to  p.  304  he  will  see  that  in  245  cases  of 
symphysiotomy  performed  by  representative  operators  in  this  and 
other  countries  the  maternal  mortality  was  7  per  cent.,  and  the  fietal 
mortality  was  10  per  cent. 

With  improved  technique,  and  above  all  more  careful  selection  of 
cases  submitted  to  pubiotomy,  both  the  maternal  and  foetal  mortality 
will  greatly  improve.  This  is  well  illustrated  in  the  latest  report  of 
Schauta 4 — fifty  cases  with  no  maternal  mortality  and  a  foetal 
mortality  of  only  6  per  cent.  Equally  good  results  were  recorded 
recently  by  Williams  of  Baltimore  in  a  series  of  twenty-five  cases. 


Conclusions  regarding-  Symphysiotomy  and  Pubiotomy. 

1.  The  operation  of  symphysiotomy  or  pubiotomy  has  a  distinct 
and  valuable  place  in  certain  well-chosen  cases.     The  cases  suitable 

1  Ann.  dc  Oyn.,  1892. 

2  Fasbender,  '  Geschichte  dcr  Gcburtshilfe,'  1900,  p.  872. 

3  '  Lehrbuch  der  Operativcn  Geburtsbilfe,'  1910. 

4  Monat.  f.  Geb.  u.  Qyn.y  January,  1910,  p.  21. 


THE  ENLAEGEMENT  OF  THE  PELVIC  CAPACITY      403 

for  the  operation  are  few  in  number,  and  have  already  been  described 
in  connexion  with  symphysiotomy. 

2.  Neither  of  these  operations  should  ever  be  performed  on  a 
primipara. 

3.  Neither  of  these  operations  is  suitable  for  domestic  practice.  It 
requires  very  great  experience  indeed  of  contracted  pelves  to  be  able  to 
determine  the  cases  suitable  for  either  operation,  and  if  a  mistake  is 
made  in  choosing  either  of  them,  most  disastrous  results  may  follow. 
The  mortality  will  be  as  high  as  Cesarean  section,  and  the  morbidity 
(injuries  to  bladder,  urethra,  etc.)  infinitely  greater. 

4.  There  is  very  little  to  choose  between  symphysiotomy  and 
pubiotomy,  but  upon  the  whole  the  latter  is  the  better. 

In  conclusion  I  would  earnestly  request  all  obstetricians  in  this  and 
other  countries  to  be  most  careful  in  their  selection  of  cases  for 
symphysiotomy  or  pubiotomy,  otherwise  they  will  undoubtedly  bring 
into  disrepute  a  most  valuable  means  at  our  disposal  for  dealing  with 
certain  cases  of  contracted  pelvis. 


CHAPTER  XXVI 

CESAREAN  SECTION 

Indications  for  the  Operation. 

As  the  results  from  Cesarean  section  have  improved,  its  limitations 
have  become  less  restricted,  so  that  the  operation  is  now  had  recourse 
to  for  conditions  which  would  not  have  been  considered  justifiable  ten 
or  fifteen  years  ago. 

The  conditions  for  which  Caesarean  section  is  most  generally  per- 
formed are  deformity  of  the  bony  pelvis  and  myomatous  and  carci- 
nomatous tumours  of  the  uterus.  In  recent  years,  however,  there 
have  arisen  advocates  for  the  operation  in  certain  cases  of  eclampsia, 
concealed  accidental  haemorrhage,  and  even  placenta  prsevia. 

In  contracted  pelvis  Cesarean  section  is  called  for  when  a  living 
child  cannot  be  born  per  vias  naturales,  and,  in  the  case  of  a  dead 
child,  when  the  risks  of  craniotomy  are  greater  than  those  of 
Cesarean  section.  From  the  previous  chapters  upon  contracted 
pelvis  and  forceps  we  have  seen  that  it  is  almost  impossible  to  deliver 
with  forceps  a  full-time  child  alive  when  the  conjugata  vera  is  less 
than  3  inches  (7*5  centimetres),  and  that  even  at  3  inches  about 
half  of  the  children  are  either  born  dead  or  succumb  shortly  to  the 
injuries  inflicted  on  them  during  their  extraction.  Unless  a  child  is 
very  small,  forceps  delivery  should  not  be  attempted  under  3£  inches. 
Even  at  3 \  inches  Caesarean  section  must  be  considered  if  there  is  a 
distinct  disproportion  between  the  head  of  the  child  and  the  maternal 
pelvis,  and  especially  if  the  pelvis  is  generally  contracted. 

As  regards  symphysiotomy  and  pubiotomy,  I  expressed  myself  as 
very  much  opposed  to  those  who  take  up  an  extreme  position  either 
for  or  against  these  operations.  I  tried  to  make  it  clear  that  I  con- 
sidered it  most  desirable  that  symphysiotomy  or  pubiotomy  should 
retain  a  place  amongst  obstetric  operations,  and  that,  to  put  it  briefly, 
they  were  indicated  in  the  case  of  a  living  child  when  our  just  failed 
to  effect  delivery  after  our  or  two  attempts  with  forceps.  I  do  not 
consider  that  symphysiotomy  or  pubiotomy  comes  into  competition 
with  Cesarean  section,  for  if  the  disproportion  between  the  head  and 

404 


CESAREAN  SECTION  405 

the  maternal  pelvis  is  so  great  as  to  lead  an  operator,  before  labour  or 
at  an  early  stage  of  labour,  to  consider  symphysiotomy,  pubiofcomy,  or 
Cesarean  section  necessary,  then,  without  doubt,  Caesarean  section  is 
the  safer  operation,  and  will  be  attended  with  better  results  for  mother 
and  child. 

Turning  now  to  the  cases  of  extreme  pelvic  deformity,  Caesarean 
section  is  indicated  whenever  the  conjugata  vera  is  below  2£  inches, 
for  craniotomy  in  cases  of  such  extreme  pelvic  deformity  is  an  opera- 
tion of  great  difficulty,  and  attended  with  a  very  high  maternal 
mortality.  Even  at  2\  to  2i  inches  (5'6  to  6'2  centimetres),  especially 
if  there  is  a  general  contraction  of  the  pelvis,  the  operation  is  one 
requiring  both  experience  and  patience.  Under  such  circumstances, 
I  have  spent  as  long  as  two  and  a  half  hours  in  extracting  the  child. 
My  results  from  craniotomy  performed  under  favourable  conditions, 
even  in  these  difficult  cases,  when  the  vera  is  2^  to  2|  inches 
(5-6  to  6-2  centimetres),  have  been  slightly  better  than  those  ob- 
tained from  Caesarean  section,  and  so,  if  the  child  is  dead,  I  prefer 
craniotomy  to  Cesarean  section. 

Here,  probably,  is  the  most  suitable  place  for  considering  the 
question  as  to  whether  or  not  one  must  always  perform  Caesarean 
section  if  the  child  is  alive  and  the  deformity  such  that  the  only 
alternative  is  craniotomy.  We  are  constantly  receiving  into  hospital 
cases  in  which  labour  is  far  advanced,  in  which  many  examinations, 
and  even  attempts  at  delivery,  have  been  made  by  midwives  and 
practitioners  whose  hands  have  not  been  thoroughly  cleansed.  In 
such  cases,  if  the  child  is  alive,  must  one  choose  Caesarean  section  ? 

Personally,  I  am  quite  convinced  that  one  considers  the  best 
interests  of  the  mother  and  of  the  State  in  deciding  against  Caesarean 
section  and  in  favour  of  craniotomy,  if  it  is  at  all  possible  to  deliver 
the  child  by  such  means.  The  general  results  in  the  Glasgow  Maternity 
Hospital  from  Caesarean  section  performed  upon  women  admitted 
advanced  in  labour,  and  previously  interfered  with,  have  been 
disastrous.  Even  supravaginal  hysterectomy,  the  operation  generally 
had  recourse  to  in  these  cases,  is  attended  with  a  very  high  maternal 
mortality.  I  agree  with  Galabin x  when  he  says  :  '  In  such  cases  the 
argument  still  holds  good  which  was  used  while  the  mortality  of 
Caesarean  section  was  very  high — that  to  perforate  a  living  child  may 
conduce  to  the  interest  even  of  foetal  life  if  it  saves  the  mother  to  bear 
more  children.'  Still  more  does  this  argument  hold  good  when  one 
thinks  that  in  many  of  these  cases  the  life  of  the  foetus  has  already 
been  endangered,  and  that  in  a  considerable  number  the  child  is 
extracted  dead  or  dies  soon  after. 

1  Brit.  Med.  Journ.,  October  11,  1902,  p.  1124. 


406  OPERATIVE  Ml  hWIl- Ki;Y 

In  recent  years  I  have  very  seldom  performed  Cesarean  section 
in  cases  which  have  heen  interfered  with  prior  to  their  coming 
under  the  care  of  myself  or  my  assistants,  unless  the  deformity  of 
the  pelvis  was  so  extreme  as  to  render  craniotomy  impossible,  or  more 
dangerous  to  the  mother  than  Ca-sarean  section.  I  am  compelled, 
therefore,  not  infrequently  to  perforate  a  living  child.  1  am  well 
aware  that  such  an  attitude  is  condemned  by  some  operators  ;  but 
each  operator  must  satisfy  himself  as  to  the  attitude  he  should 
assume  towards  such  cases.  It  is  always  with  extreme  regret  that 
I  perforate  a  living  child  ;  but  I  am  perfectly  convinced  I  save 
more  mothers  and  probably,  indirectly,  more  children.  I  do  not 
take  upon  myself  the  blame  of  destroying  the  children  ;  that  rests 
with  those  who  send  the  cases  too  late  to  hospital.  In  this  class 
of  cases  it  is  very  striking  that  Pinard,  who  is  absolutely  opposed 
to  perforating  a  living  child,  has  a  very  high  maternal  death-rate — 
20  per  cent.1  Indeed,  in  the  four  cases  where  he  performed  total 
hysterectomy  he  had  three  maternal  and  two  fcetal  deaths.  Theoreti- 
cally it  is  sound  to  take  up  the  attitude  that  no  living  child  should  be 
perforated,  but  practically  it  is  not.  Routh,2  in  his  most  valuable 
contribution  to  this  aspect  of  the  subject,  points  out  that  the  mortality 
in  such  cases  is  fully  30  per  cent,  (vide  p.  431). 

The  indications  for  Cesarean  section  when  labour  is  obstructed 
by  tumours  of  the  uterus  and  neighbouring  structures,  deformities 
and  displacements  of  the  uterus,  and  cicatrical  contractions  of 
the  vagina,  are  considered  in  the  chapters  devoted  to  these  special 
subjects. 

As  regards  eclampsia,  there  is  now  a  general  consensus  of  opinion 
that  in  certain  cases — they  are,  of  course,  few  in  number — Cesarean 
section  is  not  only  permissible,  but  is  actually  the  treatment  indicated. 
Van  den  Akker  is  credited  as  being  the  first  to  perform  the  operation 
in  1875.  The  patient  was  not  only  an  eclamptic,  but  suffered  from 
slight  pelvic  deformity.  A  hundred  years  previously  Lauverjat  recom- 
mended the  operation."  Halbertsma  performed  his  first  operation  in 
1878,  but  did  not  report  it  till  1889.  In  recent  years  all  obstetric 
writers  have  referred  to  the  subject,  and  several  monographs  with 
collections  of  cases  have  appeared  in  obstetric  journals,  more  especially 
in  Germany.  Among  the  more  important  are  those  by  Hillman,4 
Streckeisen,5  and  Croom.0 

1  Ann.  de  Gyn.  et  d'Obst.,  September,  1907.  p.  529. 

2  Journ.  of  Obst.  and  Gyn.  of  Brit.  Empire,  January,  1911. 
:i  Fasbender,  '  Geschichte  der  Geburtshiilfe,"  1906,  p.  804. 

*  Monat.f  Geb.  u.  Gyn.,  Bd.  x.,  Heft  2.  6  Cent./.  Gyn.,  190:5,  p.  1072. 

6  Trans.  Edin.  Obst.  Soc,  vol.  xxix.,  p.  194. 


CESAREAN  SECTION  407 

The  cases  in  which  the  operation  is  indicated  are  when  the 
eclamptic  seizures  are  of  great  severity  and  frequency  in  the  later 
weeks  of  pregnancy,  and,  above  all,  when  the  cervix  is  not  taken  up 
and  is  very  rigid  and  undilatuble.  This  is  not  the  place  to  discuss 
the  treatment  of  eclampsia.  I  would  only  say  that,  with  my  present 
experience,  I  am  strongly  opposed  to  radical  operative  interference 
until  saline  transfusion  and  the  administration  of  chloral  or  morphia 
have  been  given  a  full  trial.  On  many  occasions  I  have  seen  eclampsia 
arrested  by  such  treatment.  If,  however,  after  two  hours  the  progress 
of  the  disease  is  not  arrested  by  these  measures,  I  consider  emptying 
of  the  uterus  not  only  justifiable,  but  absolutely  indicated. 

Caesarean  section  in  eclampsia  comes  into  competition  with  '  Vaginal 
Cajsarean  Section '  and  forcible  dilatation  of  the  cervix  by  means  of 
metal  dilators.  Metal  dilators  in  most  cases  at  term  are  quite  unsuit- 
able if  the  cervix  is  not  taken  up.  Vaginal  Caesarean  section  in  the 
case  of  a  primipara  at  term  is  an  operation  attended  with  consider- 
able difficulty ;  I  would  therefore  confine  it  to  cases  in  the  earlier 
months  of  pregnancy.  In  the  later  months  the  abdominal  operation 
is  more  easily  carried  out.  This  whole  subject  is  fully  considered  in 
Chapter  XXVIII. 

As  regards  the  results  from  abdominal  Cesarean  section,  all  are 
agreed  that  the  maternal  mortality  is  extremely  high.  It  must,  how- 
ever, be  remembered  that  only  the  very  worst  cases  are  treated  by 
this  method,  and  that,  consequently,  one  cannot  expect  other  than  a 
high  death-rate.     Berkeley1  puts  the  mortality  at  47  per  cent. 

Caesarean  section  in  accidental  haemorrhage  and  placenta  praevia 
is  considered  in  connexion  with  the  treatment  of  these  conditions. 
I  would  only  remark  here  that,  while  many  are  in  favour  of  Caesarean 
section  followed  by  hysterectomy  in  severe  cases  of  concealed  acci- 
dental haemorrhage,  very  few  approve  of  such  radical  treatment  for 
placenta  praevia. 

In  addition  to  the  conditions  mentioned,  Gemmell2  and  Kohn3 
refer  to  the  performance  of  the  operation  in  myasthenia  gravis. 

Preparation  of  the  Patient. — In  all  abdominal  operations  the 
great  danger  is  septic  infection,  and  in  few  is  this  more  likely  to  occur 
than  in  Caesarean  section.  In  addition  to  the  ordinary  risks  through 
the  abdominal  wound,  there  are  all  the  dangers  through  the  par- 
turient canal.  The  uterus  left  behind,  and  containing  as  it  does 
debris  of  decidua  and  blood-clot,  with  large  dilated  veins  and  lym- 
phatics running  from  it,  furnishes  a  most  suitable  soil  for  the  growth 

1  Jour?i.  of  Obst.  and  Gijn.  of  Brit.  Empire,  December,  1904,  p.  476. 

2  Prag.  Med.  Woch.,  May  14,  1903,  p.  242. 

3  Journ.  of  Obst.  and  Gyn.  of  Brit.  Empire,  March.  1904,  p.  271. 


40H  OPERATIVE   MIDWIFERY 

and  di>semination  of  any  micro-organisms  which  may  be  introduced 
into  it  either  through  the  abdominal  wound  or  the  vagina.  Then, 
the  operation  has  frequently  to  be  performed  upon  women  hurriedly 
prepared. '  But,  even  worse  than  that,  not  infrequently  the  patients 
sent  into  hospital  are  advanced  in  labour,  and  in  very  many  cases 
have  been  previously  examined  by  midwives  and  practitioners  whose 
hands  have  not  been  thoroughly  cleansed.  So  serious  is  this  latter 
factor,  and  so  unsatisfactory  are  the  results  from  Ca-sarean  section, 
that  many  of  us  now  are  disinclined  to  perform  the  operation  in  such 
cases  unless  there  is  absolutely  no  alternative.  As  I  have  already 
said,  some  of  us  even  go  the  length  of  perforating  and  destroying 
a  living  child,  for  in  such  cases  one  cannot  reckon  upon  a  maternal 
mortality  of  less  than  20  per  cent.  One  is  confronted,  therefore,  by 
this  unfortunate  state  of  matters — that  Cesarean  section,  the  simplest 
of  all  abdominal  operations,  is  attended  with  a  higher  mortality  than 
ovariotomy  or  hysterectomy  for  myomata,  for  example.  This  can  only 
be  remedied  by  the  medical  practitioners  appreciating  the  limitations 
of  forceps,  doing  everything  to  prevent  infection,  and,  if  they  are  not 
prepared  to  perform  Cesarean  section,  sending  their  patients  into 
hospital  in  the  last  days  of  pregnancy  or  very  early  in  labour. 

It  is  a  distinct  advantage  to  have  the  patient  in  hospital  for  some 
days  before  the  operation.  To  arrange  this  is  not  always  easy,  for  the 
onset  of  labour  is  not  a  date  one  can  fix  with  exactness.  My  own 
practice  is  to  bring  the  patient  into  hospital  or  nursing  home  a  week 
before  labour  is  expected.  If  she  delays  going  into  the  institution 
until  the  last  moment,  she  may  be  taken  in  labour  before  she  can  get 
there.  There  is  another  advantage  of  having  a  patient  in  hospital 
for  some  time  before  Cesarean  section.  Many  of  the  cases  of  severe 
rickets  when  they  are  admitted  to  hospital  show  signs  of  considerable 
bronchitis,  and  if  a  severe  operation  with  a  prolonged  anaesthesia  is 
performed  immediately  after  their  admission,  the  bronchitis  often 
becomes  extreme.  On  one  or  two  occasions  I  have  been  very  anxious 
indeed  regarding  patients  in  this  respect. 

The  preparation  of  the  abdominal  wall  prior  to  operation  is  fully 
considered  in  Chapter  XXI. 

Until  recently  it  was  my  custom  to  cleanse  the  vagina  very 
carefully  prior  to  operation.  During  the  last  two  years  I  have 
abandoned  this  procedure  except  in  those  rare  cases  in  which  I 
perform  Casarean  section,  although  the  vaginal  canal  has  possibly 
become  infected. 

Time  for  Operating1. — At  this  point  it  is  advisable  that  I  refer  to 
the  time  for  operating.  It  was  the  custom  until  a  few  years  ago,  and 
is  still  the  recommendation  of  some  surgeons,  to  operate  only  after 


CESAREAN  SECTION  409 

labour  has  been  in  progress  some  Httle  time.  Those  who  advocate 
this  claim  that,  if  the  cervix  is  dilated,  any  blood-clot  forming  in  the 
uterus  is  more  readily  expelled ;  in  other  words,  that  drainage  is 
better,  and  that  post-partum  hemorrhage  is  less  likely  to  occur. 
Others  maintain  that  it  is  better,  when  one  has  the  choice,  to  operate 
prior  to  the  onset  of  labour,  because  one  can  choose  the  most  suitable 
time  in  the  day,  and  quietly  make  every  preparation.  These  latter 
■claim  that  the  uterus  finds  no  difficulty  in  expelling  any  clots  that 
may  form  in  its  cavity,  and  that  the  danger  of  post-partum  hemor- 
rhage  is  theoretical.  Personally,  I  think  there  is  much  to  be  said  in 
favour  of  operating  before  labour  has  commenced.  In  multipara;  I 
always  do  so  if  possible,  and  I  have  never  seen  any  trouble  result. 
On  two  occasions,  however,  in  primigravide  considerable  disturbance 
from  after-pains  followed.  In  consequence  of  this,  I  delay  operating 
upon  them  until  labour  has  begun.  wnav: 

Operating  before  labour  has  commenced  is  naturally  only  suitable 
for  those  cases  in  which  there  is  absolutely  no  doubt  that  Cesarean 
section  is  necessary.  If  there  is  any  doubt  about  this,  and  any 
probability  of  the  labour  being  terminated  spontaneously  by  forceps, 
symphysiotomy,  or  pubiotomy,  the  patient  must  be  allowed  to  go  into 
labour,  and  possibly,  indeed,  the  latter  must  be  allowed  to  continue 
for  some  time  before  Cesarean  section  is  performed. 

There  is  a  danger  in  operating  before  the  onset  of  labour  that  one 
may  occasionally  perform  the  operation  before  term  has  been  reached, 
and  so  deliver  a  child  distinctly  premature.  Hospital  patients  are 
often  so  uncertain  regarding  the  onset  of  pregnancy,  and  the  abdo- 
men in  the  rachitic  becomes  early  so  prominent,  that  it  is  impossible 
by  palpation  to  estimate  the  size  of  the  child.  It  was  once  my 
experience  to  deliver  a  child  which,  as  far  as  could  be  judged  after 
delivery,  was  not  more  than  thirty-six  weeks  old.  "When,  however, 
the  patient's  statements  regarding  the  duration  of  her  pregnancy  are 
reliable,  the  likelihood  of  performing  the  operation  much  before  term 
is  reduced  almost  to  the  vanishing-point. 

The  actual  operation  is  just  as  easy  in  the  pregnant  as  in  the 
parturient,  and  the  uterus,  I  find,  contracts  equally  well  in  both.  If 
one  has  to  remove  the  uterus,  it  is  a  distinct  advantage  to  operate 
before  labour,  for  there  is  a  much  smaller  stump  to  stitch,  as  the 
calibre  of  the  cervical  canal  is  much  narrower.  When,  therefore, 
hysterectomy  is  called  for,  the  operation  should  always  be  performed, 
if  possible,  before  labour  has  started. 

Immediately  before  commencing  the  operation  a  full  dose  of 
ergotin  should  be  given  hypodermically.  It  is  a  mistake  to  give  it 
too  soon,  especially  if  the  labour  has  been  going  on  for  long,  as  there 
may  be  some  little  trouble  in  extracting  the  child. 


110 


UPKUAT1YE  MIDWII  i:i:V 


The  Operation. 

The  Abdominal  Incision. — The  abdominal  incision  should  be  high 
and  sufficiently  long.  It  should  be  high,  because  one  can  open  into 
the  uterus  high  up  on  the  fundus.  My  rule  is  to  make  an  incision 
8  to  10  inches  ('20  to  25  centimetres)  in  length,  the  length  depending 
upon  whether  or  not  I  intend  to  turn  the  uterus  out  of  the  abdomen 
before  opening  into  it.  Two-thirds  of  this  incision  is  made  above  and 
one-third  below  the  level  of  the  umbilicus  (Fig.  188).     If  it  is  the 


Fig.  188. — The  Abdominal  Incision  — Two-thhds  above  and  One-third  below  the  Umbilicus. 


operator's  intention  to  remove  the  uterus  the  incision  should  be  made 
lower. 

Having  opened  into  the  abdominal  cavity,  one  has  to  decide 
whether  or  not  the  uterus  should  be  turned  out  of  the  abdomen. 
There  is  no  doubt  that  if  the  uterus  is  not  turned  out  before  it  is 
emptied,  the  abdominal  incision  may  be  kept  about  2  inches  (5  centi- 
metres) shorter,  and  that,  of  course,  is  a  slight  advantage.  On  the 
other  hand,  the  abdominal  cavity  can  be  kept  cleaner  by  turning  the 
uterus  out.  On  theoretical  grounds  the  advantages  are  in  favour  of 
turning  out  the  uterus,  and  personally  I  prefer  it.     Others — as,  for 


CESAREAN  SECTION  411 

example,  Schauta1 — prefer  not  to  turn  out  the  uterus.  It  is  really  a. 
matter  of  no  very  great  importance,  except  in  those  cases  where  the 
membranes  have  ruptured  some  time  before,  for  then  there  is  a 
danger  that  the  uterus  may  have  become  infected  through  the  vagina. 
Consequently,  in  such  cases  the  uterus  should  always  be  turned  out 
before  being  opened  into. 

If  it  is  decided  to  open  the  uterus  while  it  still  remains  in  the 
abdomen,  the  hand  should  be  passed  round  to  the  right  side  of  the 
abdomen  and  the  uterus  rotated  to  the  left  so  as  to  correct  the  torsion 
to  the  right  so  commonly  present.  By  so  doing  the  uterus  can  be 
opened  in  the  middle  line,  which  is  always  an  advantage.  The  uterus 
should  then  be  surrounded  by  large  sterilized  swabs,  to  prevent  as  far 
as  possible  blood  and  liquor  amnii  getting  into  the  abdominal  cavity. 

If,  on  the  other  hand,  it  is  decided  to  turn  the  uterus  out  before 
opening  into  it,  the  hand  should  be  passed  up  over  the  fundus,  when, 
if  the  abdominal  incision  has  been  long  enough  and  high  enough, 
there  is  no  difficulty  in  bringing  the  uterus  out.  After  having  turned 
it  out,  the  abdominal  wound  above  should  be  temporarily  closed  by 
means  of  pressure  forceps,  and  the  uterus  surrounded  by  sterilized 
swabs  or  towels. 

The  Uterine  Incision. — The  recognized  uterine  incision  is  a 
longitudinal  one  running  down  the  middle  of  the  anterior  wall  of  the 
uterus.  It  should  be  limited  to  the  active  contractile  portion  of  the 
organ,  and  should  not  extend  into  the  lower  uterine  segment.  There 
are  several  objections  to  cutting  into  the  lower  uterine  segment,  and 
of  these  the  most  important  are :  that  the  wall  is  very  thin  ;  that  the 
wound  is  brought  nearer  to  the  vagina,  and  so  there  is  greater  risk  of 
infection  ;  and  that  in  extracting  the  child  the  lower  end  of  the  wound 
is  very  apt  to  tear.  Another  disadvantage  is  that,  in  stitchin  g  the 
lower  segment,  if  thick  silk  ligatures  are  employed,  they  may  find  their 
way  into  the  bladder.  Several  cases  of  this  kind  have  been  reported. 
Especially  interesting  was  one  described  by  Cameron,  in  which  three 
large  stones  were  removed  from  the  bladder  of  a  patient  upon  whom 
he  had  performed  Caesarean  section  some  few  years  before.  The 
nucleus  of  each  stone  was  a  silk  ligature. 

The  longitudinal  incision  is  not  the  only  one  which  has  been 
advocated.  Kehrer  recommended  a  low  transverse  incision  ;  Johan- 
nowsky  a  posterior  longitudinal ;  Cohnheim  a  posterior  longitudinal 
one  with  drainage  through  Douglas'  pouch  into  the  vagina  ;  Caruso 
and  Miiller  a  sagittal  fundal  incision;  and  Fritsch'2  a  transverse 
fundal  one. 

1  Archivf.  Gyn.,  1906,  Bd.  lxxix.,  Heft  1. 

2  Zentraiblait  f.  Gyn.,  1897,  p.  561. 


412  OPERATIVE  MIDWIFER1 

But  the  incision  which  in  recent  years  has  been  most  discussed 
is  the  extraperitoneal  one  associated  more  particularly  with  the  names 
of  Sellheim  and  Latzko.  It  will  he  referred  to  at  the  end  of  this 
chapter  in  some  detail.  In  1S97  Fritech1  recommended  a  transverse 
fundal  incision,  and  claimed  that  it  possessed  the  following  advantages: 
(a)  The  abdomen  being  opened  into  high,  there  is  less  risk  of  subse- 
quent hernia  ;  (/<)  by  pulling  forward  the  fundus  the  escape  of  blood 
and  liquor  amnii  into  the  abdominal  cavity  is  better  prevented  ; 
(c)  the  child  is  more  easily  extracted;  (rf)  the  placenta  is  less 
frequently  cut  down  upon;  (c)  there  is  less  bleeding;  (/J  there  is 
greater  diminution  of  the  wound  and  less  stitching  required. 

After  employing  the  incision  in  some  nine  cases,  I  discussed  the 
matter  in  detail  in  two  papers.2  My  conclusions  were  that  the  first 
two  advantages  mentioned  would  be  obtained  with  the  ordinary 
incision  if  the  abdomen  were  opened  into  high  enough,  and  the 
uterus  turned  out  before  opening  into  it.  The  third  advantage,  that  the 
child  is  more  easily  extracted,  I  was  inclined  to  admit,  for  when  the 
waters  have  drained  away  there  is  occasionally  slight  difficulty  in 
•extracting  the  child  through  a  longitudinal  incision.  The  difficulty, 
however,  is  only  slight,  although  on  two  occasions  I  have  seen 
difficulty  in  extracting  the  head,  which  was  firmly  grasped  below  the 
retraction  ring.  Curiously  enough,  Steinthal3  reported  a  case  of  the 
same  difficulty  where  a  fundal  incision  was  employed,  and  so  firm  was 
the  grasp  of  the  head  that  he  was  forced  to  make  a  longitudinal 
incision  through  the  retraction  ring  before  he  could  get  the  head 
removed.  The  fourth  advantage  claimed,  that  the  placenta  is  less 
frequently  cut  down  upon,  I  did  not  find  was  the  case,  for  1  encoun- 
tered it  in  40  per  cent,  of  my  cases.  Others  have  had  a  similar 
experience.  Schroeder4  encountered  the  placenta  in  35  per  cent., 
Hiibl5  in  41  per  cent.,  V.  Braun-Fernwald6  in  54  per  cent.  It 
certainly  is  preferable  not  to  cut  down  upon  the  placenta,  for  there  is 
always  more  bleeding  when  one  encounters  it,  and  the  stitching  of  the 
uterus  is  not  so  satisfactory  ;  besides,  risks  of  infection  are  slightly 
increased.  The  other  advantages,  that  there  is  less  bleeding  and 
greater  diminution  of  the  wound,  did  not  impress  me,  although  I  was 
disposed  to  think  that  the  transverse  incision  contracted  more  than 
the  longitudinal. 

1  Zentralblatt  f.  Gyn.,  1897,  p.  561. 

2  Journ.  of  Olsf.  and  Gyn.  of  Brit.  Empire,  vol.  ii..  1802,  p.  21  ;  or.d  Bi  it.  Med. 
Jvwrn.,  vol.  ii.,  1902,  p.  1129. 

3  Zent.f.  Gyn.,  1898,  p.  345. 

*  Monat.f  Geb.  it.  G-yn.,  P.d.  xiii.,  1901.  p.  22. 

6  Ibid.,  Ed.  xii.,  1900,  p.  480.  6  Archivf.  Gyn.,  Bd.  lix.,  1899,  p.  820. 


CESAREAN  SECTION 


41S- 


The  objections  urged  against  the  incision,  that  the  fundus  uteri 
contracts  adhesions  to  the  bowels,  that  a  high  attachment  of  the 
fundus  to  the  abdominal  wall  results,  and  that  involution  of  the 
uterus  is  in  consequence  interfered  with,  are  not  of  much  importance. 
I  admit,  however,  that  rupture  of  the  uterus  at  a  subsequent  preg- 
nancy is  more  liable  to  occur  with  a  fundal  than  with  a  longitudinal 
incision.  As  a  matter  of  fact,  rupture  of  the  fundal  cicatrix  did  occur 
in  one  of  my  cases  at  a  subsequent  pregnancy.  The  case  is  described 
and  the  uterus  figured  in  Chapter  XXXY. 


Fig.  189. — Showing  bulging  of  Membranes  through  Uterine  Incision. 

One  could  not  but  feel  that  the  excitement  in  Germany  regard- 
ing Fritsch's  incision  was  out  of  all  proportion  to  the  importance 
of  the  subject,  I  quite  agree  with  Bar  when  he  wrote  regarding  it  : 
'  Je  regarde  la  modification  de  Fritsch  pour  peu  importante  et  je 
m'en  tiens  encore  a  l'incision  longitudinale  pratiqnee  aussi  haut  que 
possible.n 

The  longitudinal  incision  should  be  from  6  to  7  inches  (15  to 
18  centimetres)  in  length,  and,  as  I  have  already  stated,  should  be 
placed  high  on  the  anterior  wall  in  the  middle  line.  In  cutting  through 
the  wall,  very  free  bleeding  occurs,  especially  if  the  placenta  is  situated 

1  '  Le./ons  de  Pathologie  Obstctricale,'  1900,  p.  20. 


-114 


OPERATIVE  MIDWIFERY 


anteriorly.  The  slight  inconvenience  of  this  may  be  lessened  by  the 
operator  and  his  assistant  pressing  on  the  uterus  with  a  swab  just 
outside  the  incision.  This  has  the  effect  of  controlling  the  haemor- 
rhage, except  when  the  placenta  is  situated  underneath  the  incision. 

The  operator,  when  opening  the  uterus,  cuts  down  carefully  upon 
the  membranes,  which  when  reached  bulge  out  through  the  incision 
(Fig.  189).  Two  lingers  are  then  inserted  between  the  membranes 
and  the  uterine  wall,  and  the  incision  is  quickly  enlarged  upwards  to 
the  extent  required  (Fig.  190).     The  membranes  are  then  ruptured, 


Fig.  190.—  Enlarging  the  Uterine  Incision. 

1  and  the  child  seized  and  extracted.     In  cutting  down  upon  the  mem- 
branes one  often  punctures  them,  but  this  is  of  no  consequence. 

The  placenta  is  encountered  in  some  40  per  cent,  of  cases.  In 
such  cases  the  operator  on  reaching  the  placenta  slips  his  fingers  up 
between  it  and  the  uterine  wall,  enlarges  the  incision,  and  extracts 
the  placenta  quickly;  or,  better  still,  pushes  his  hand  through  the 
placenta  and  seizes  hold  of  the  child,  just  as  he  would  do  in  perform- 
ing version  in  a  case  of  '  central  placenta  pra  via.'  To  open  the  uterus, 
as  Olshausen1  has  suggested,  in  the  part  where  the  placenta  is  not 
situated    has  not  been  found  practical,  for  it  is  not  always  possible 

1   Zent.f.  Gyn.,  No.  1,  1900.  p.  1. 


CESAREAN  SECTION 


lir- 


to  make  sure  of  its  position,  and  valuable  time  is  lost  in  trying  to  do 
so.  Olshausen  claims  that  the  area  where  the  placenta  is  situated  has 
visibly  dilated  vessels. 

I  have  not  been  able  to  confirm  the  observation  of  Bayer,  Leopold, 
and  Palm,  that  when  the  placenta  is  situated  anteriorly  the  distance 
between  the  tubes  anteriorly  is  increased,  and  when  situated  posteriorly 
the  distance  between  them  posteriorly  is  increased.  Holzapfel,  Koblanck,1 
and  Olshausen  also  question  the  correctness  of  the  observation. 


Fig.  191. — The  Hand  has  been  pushed  through  the  Membranes  and  a  Foot  seized. 

The  extraction  of  the  child  is  best  accomplished  by  seizing  one  or 
both  feet  (Fig.  191),  for  with  a  high  uterine  incision,  except  in  cases 
of  breech  presentation,  the  head  is  more  difficult  to  reach.  There  is 
almost  never  any  difficulty  in  extracting  the  head.  The  cases  in  which 
I  have  found  difficulty  are  where  the  waters  have  drained  away,  and 
the  uterus  is  firmly  applied  to  the  surface  of  the  child.  I  have  twice 
seen  the  neck  grasped  by  the  retraction  ring ;  but  in  both  cases  the 
difficulty  was  overcome  without  cutting  through  the  retraction  ring, 
as  Steinthal 2  required  to  do. 

If  too  small  an  incision  has  been  made,  the  uterus  may  contract 

1  Zeitschrift  f.  Geb.  u.  Gijn.,  Bd.  xlvi.,  Heft  1,  1901,  p.  99. 

2  Zent.f.  Gyn.,  1898,  p.  345. 


•lie 


OPERATIVE   MIDWIFERY 


firinly  round  the  head  ;  but  a  slight  extension  of  the  incision  up  wards- 
overcomes  this  difficulty.  It  is  a  mistake  to  try  and  drag  the  child 
through  a  small  incision,  for  the  uterus  is  very  apt  to  be  torn,  and  if 
this  occurs  downwards,  as  it  generally  does,  an  irregular  and  ragged 
tear  is  made  in  the  lower  segment. 

Whenever  delivery  is  completed,  the  umbilical  cord  should  be 
clamped  with  forceps  and  cut,  and  the  child  handed  over  to  the 
assistant  who  is  ready  to  look  after  it.  The  child  cries  very  soon 
(Chapter  XXXVII.),  but  the  apnoea  may  continue  for  some  seconds. 


FlG.  192. — The  Removal  of  the  Secuudines. 

As  the  child  is  extracted,  the  assistant  seizes  the  uterus,  and  if  it  is- 
not  already  outside  the  abdomen,  brings  it  out  and  surrounds  it  with 
large  swabs.  He  then  kneads  it  firmly,  which  causes  it  to  contract 
and  arrests  all  haemorrhage. 

There  remains  now  only  the  removal  of  the  placenta  and  mem- 
branes, and  it  is  of  the  greatest  importance,  if  the  uterus  is  left 
behind,  that  these  should  be  completely  removed  (Fig.  192).  When 
the  membranes  have  bulged  down  into  the  vagina,  there  is  a  risk  of 
infection  in  pulling  them  back  up  through  the  uterus.  If  the  os  is 
sufficiently  dilated,  this  difficulty  may  be  overcome  by  separating  the 
placenta  and  membranes,  and  pushing  them  down  through  the  cervix, 
by  means  of  a  large  swab. 


CESAREAN  SECTION  417 

The  Treatment  of  the  Uterus. — There  are  three  different  courses 
open  to  one  after  extracting  the  child :  (a)  Removal  of  the  uterus  by 
supravaginal  hysterectomy,  formerly  known  as  Porro's  operation, 
when  the  stump  was  treated  extraperitoneally  ;  (b)  panhysterectomy  ; 
(c)  retention  of  the  uterus  without  sterilization,  the  true  conservative 
Cesarean  section  ;  (d)  retention  of  the  uterus  and  the  sterilization 
of  the  patient  by  removing  a  portion  of  the  tubes. 

Each  of  these  methods  has  its  advantages,  and  must  be  considered 
in  some  detail. 

(a)  Removal  of  the  Uterus  by  Supravaginal  Hysterectomy,  formerly 
known  as  Porro's  Operation,  when  the  Stump  was  treated  Extra- 
peritoneally.— The  removal  of  the  uterus  after  the  extraction  of  the 
child  is  indicated  in  cases  where  there  is  a  probability  that  the 
parturient  canal  is  infected,  when  myomatous  tumours  are  too  extensive 
or  too  numerous  to  permit  of  simple  myomectomy  ;  when  post-partum 
haemorrhage  cannot  be  controlled  ;  when  the  uterus  has  been  too 
much  injured  by  rupture  or  previous  Cesarean  sections  to  justify  one 
leaving  it  behind  ;  and  in  women  the  subjects  of  osteomalacia.  All 
the  indications  are  self-evident  and  need  no  elaboration,  with  the 
exception  of  post-partum  haemorrhage.  This  condition  I  have  only 
once  observed.  The  patient  had  been  long  in  labour,  and  was  driven 
some  twenty  miles  before  operation.  All  other  operators  of  experience 
have  remarked  upon  the  infrequency  of  post-partum  haemorrhage. 

Every  one  admits  that  Porro's  operation  for  some  years  after  its 
introduction  gave  the  best  results.  It  was  introduced  by  him  in  1876, 
but  was  suggested  many  years  before  by  Cavallini  and  Blundell,1  the 
latter  Professor  of  Obstetric  Medicine  in  Guy's  Hospital.  Each 
suggested  the  operation  after  making  experiments  upon  the  lower 
animals.  Blundell  did  the  operation  upon  four  rabbits,  three  of  which 
recovered.1 

The  true  Porro  operation  consisted  in  a  supravaginal  amputation 
of  the  uterus,  the  pulling  of  the  stump  up  through  the  lower  part 
of  the  abdominal  wound,  the  fixing  of  the  stump  there  with  long 
pins,  and  the  passing  round  it  of  a  serre-noeud,  which  was  slowly 
tightened  until  it  cut  through  the  stump.  The  abdominal  wound 
was  closed  in  the  ordinary  way.  The  method  was  a  very  crude  one, 
and  suppuration  often  occurred  about  the  stump  and  lower  part  of  the 
wound,  so  that  the  healing  was  very  protracted  and  the  mortality  was 
high.  Improvements  soon  began  to  be  made,  such  as  opening  of  the 
uterus  only  after  it  had  been  turned  out  of  the  abdomen,  and  con- 
trolling haemorrhage  by  the  application  of  the  tourniquet.  The 
greatest  improvement,  however,  arose  as  a  result  of  Hegar's  method 

1  '  Obstetric  Medicine,'  p.  367. 

27 


•118  OPERATIVE   MimYIFERY 

of  treating  the  stump  in  hysterectomy  for  myoma.  Hegar  separated 
the  peritoneum,  stitched  it  to  the  wound,  and  then  dealt  with  the 
stump  entirely  extraperitoneal^.  This  method  was  perfected  by 
Fehling  and  others  on  the  Continent,  and  by  Lawson  Tait  in  this 
country. 

While  the  extra-abdominal  treatment  of  the  stump  was  being 
perfected,  others  were  engaged  in  trying  to  devise  a  suitable  method 
of  treating  it  intra-abdominally.  The  earliest  device  suggested,  and 
carried  out  in  a  few  cases — it  now  seems  a  very  primitive  one — 
was  to  invert  the  stump  or  the  whole  uterus  into  the  vagina.  Again, 
the  great  advance,  although  it  was  somewhat  slow  in  being  appre- 
ciated, came  as  a  result  of  improvements  in  the  technique  of  hyster- 
ectomy for  myoma.  With  greater  experience  and  attention  to  aseptic 
precautions,  Schroder's  method  of  stitching  the  stump  and  dropping 
it  back  into  the  abdomen  gave  such  satisfactory  results  that 
obstetricians  came  to  adopt  it  also.  At  the  present  time,  with  the 
peritoneum  carefully  stitched  over  the  stump,  it  is  the  method 
generally  employed  when  the  uterus  is  removed  by  supravaginal 
amputation. 

The  extra-abdominal  treatment  of  the  stump  is  still  favoured  by 
a  few  operators  in  septic  cases,  for  they  claim  that  by  that  method 
infection  is  better  prevented.  Should  it  be  had  recourse  to,  the 
uterus  is  turned  out  of  the  abdomen  and  amputated,  the  peritoneum 
turned  back  and  stitched  to  the  abdominal  wound,  and  two  pins 
introduced  at  right  angles  to  prevent  the  stump  being  retracted. 

The  modern  method,  which  is  still  erroneously  referred  to  as  Porro's 
operation,  consists  in  securing  the  uterine  and  ovarian  vessels  on 
both  sides  by  ligatures,  amputating  the  uterus  supravaginal!}*,  stitch- 
ing the  stump,  and  finally  bringing  the  peritoneum  by  a  continuous 
suture  over  the  stump — a  method  which  is  correctly  described  as 
retroperitoneal  or  subperitoneal  treatment  of  the  stump.  The  details 
of  the  operation  are  briefly  as  follows  :  The  patient  is  placed  in  the 
Trendelenburg  position,  and  the  intestines  are  carefully  walled  off 
with  swabs.  The  uterus,  being  pulled  out  of  the  abdomen,  is  dragged 
over  towards  one  side  by  the  assistant,  so  as  to  allow  the  operator  to 
reach  the  broad  ligament  of  the  opposite  side.  The  haemorrhage  from 
the  wound  in  the  uterus  is  controlled  by  a  long  clamp,  or  by  rapidly 
stitching  up  the  uterine  wound  (Fig.  193).  Clamps  are  now  applied, 
first  to  the  round  ligaments  and  then  to  the  ovarian  vessels,  either 
beyond  or  on  the  uterine  side  of  the  ovary,  according  as  one  decides 
to  remove  or  leave  the  latter  behind.  A  clamp  is  then  applied  close 
down  the  side  of  the  uterus,  to  control  any  bleeding  from  the  ovarian 
vessels  on  the   uterine   side.      The    tubes   and   ovarian   vessels   are 


CESAREAN  SECTION 


4V.) 


then   divided.     Any  vessels  which  have  not  been  included  should  be 
clamped. 

The  securing  of  the  uterine  vessels — the  next  step — is  the  only 
troublesome  one  in  the  operation.  Prior  to  attempting  to  secure 
them,  however,  the  peritoneum  on  the  anterior  uterine  wall  should 


Fig.  193. — Supravaginal  Amputation  of  Uterus. 

be  divided  transversely,  just  above  where  it  is  reflected  on  to  the 
bladder.  In  doing  this  the  peritoneum  alone  should  be  seized  with 
dissecting  or  pressure  forceps  and  cut  across.  If  one  catches  it  care- 
lessly, the  subjacent  cellular  tissue,  which  contains  numerous  dilated 
vessels,  will  be  injured,  and  profuse  bleeding  will  result.  The  bladder 
is  then  pushed  down  out  of  the  way  with  a  gauze  swab.     The  peri- 


120 


OPERATIVE  MIDWIFERY 


toneum  behind  the  uterus  is  also  divided.  <  >ne  has  now  opened  up 
the  lower  part  of  the  broad  ligament,  and  tin-  uterine  vessels  of  each 
side  can  be  readily  seen  and  felt.  The  vessels  are  secured  by  clamp- 
applied  close  to  the  cervix  in  case  of  injuring  the  ureters,  although 
there  is  really  not  much  chance  of  doing  this  if  the  bladder  has  been 


Fig.  194. — Stitching  Stump  of  Dilated  Cervix. 

pushed  well  out  of  the  way.  .   Having  secured  both  uterine  vessels, 
they  are  divided  close  by  the  uterus. 

Having  grasped  the  cervix  with  vulsellum  forceps  below  the  level  at 
which  it  is  to  be  divided,  the  cervix  is  cut  across  and  the  body  of  the 
uterus  removed.  The  vessels  which  have  been  clamped  must  now 
be  ligated,  and  this  I  prefer  to  do  by  '  under-stitching.'  There  now 
remains  only  the   stitching  of  the  stump,  which  is  steadied  by  the 


CESAREAN  SECTION  421 

vulsellum  forceps.  Prior  to  doing  this,  however,  I  am  in  the  habit 
of  swabbing  out  the  cervical  canal  with  pure  carbolic ;  others  use 
the  Pacquelio  cautery,  or  dissect  out  the  mucous  membrane.  I  do 
not  attach  great  importance  to  these  steps,  and  many  operators 
dispense  with  them  altogether.     The  actual  stitching  of  the  cervix 


Fig.  195. — Covering  the  Stump  with  Peritoneum. 

must  be  done  with  care.  I  usually  do  it  in  two  layers  (Fig.  194). 
The  sutures,  which  are  of  catgut,  are  passed  through  the  anterior  and 
posterior  walls  of  the  cervix,  but  do  not  include  the  mucous  membrane. 
The  amount  of  stitching  that  is  necessary  depends  upon  the  width  of 
the  cervix.  In  the  case  of  a  dilated  cervix  the  stump  to  be  stitched  is 
very  broad,  so  that  five  deep  and  two  or  three  superficial  sutures  are 
required,  while,  on  the  other  hand,  if  the  cervix  has  not  been  dilated 


422  OPERATIVE  MIDW1 1T.I;Y 

and  the  stump  is  quite  small,  two  deep  and  one  or  two  superficial 
sutures  are  sufficient. 

Having  again  satisfied  oneself  that  there  is  no  bleeding -point  un- 


Fn:.  196.  —  Panhysterectomy. 

Upper  part  of  vagina  is  clamped  across,  and  the  operator  is  pushing  gauze  into  lower 

part  of  vagina. 

secured,  the  peritoneum  is  carefully  stitched  over  the  stump,  and  the 
raw  surface  of  the  broad  ligament  brought  together  with  a  continuous 


CESAREAN  SECTION 


423 


catgut  suture  (Fig.  195).  All  blood-clot  is  now  removed,  and  if  the 
patient  is  at  all  collapsed,  1  or  2  pints  of  normal  saline  solution  are 
poured  into  the  abdomen.  The  closing  of  the  abdomen  is  considered 
later. 

(1>)  Panhysterectomy. — When  the  uterus  has  to  be  removed,  a  few 
operators  prefer  total  hysterectomy,  especially  in  septic  cases ;  it  is 
also  indicated  in  carcinoma  of  the  cervix,  and  in  certain  cases  of 
uterine  myoma  and  rupture. 

The  steps  in  the  operation  are,  up  to  the  point  of  clamping  the 
uterine  vessels,  the  same  as  those  followed  in  supravaginal  amputa- 
tion. The  bladder  must  now  be  pushed  farther  down,  and  the  tissues 
around  separated  from  the  cervix  and  the  upper  part  of  the  vagina. 


Fig.  197. — Conservative  Cesarean  Section. 

The  assistant  controlling  the  bleeding  and  bringing  the  edges  of  the  wound  together. 
prior  to  the  operator  introducing  the  sutures. 


The  latter  is  then  clamped  with  forceps  curved  at  the  ends  (Fig.  196). 
The  vagina  is  then  divided  below  and  gauze  is  packed  into  the  canal. 
This  prevents  any  of  the  uterine  discharges  contaminating  the  peri- 
toneum. The  anterior  and  posterior  vaginal  walls  are  then  stitched 
together,  special  care  being  taken  at  the  corners,  for  there  is  apt  to  be 
a  little  venous  oozing  there.  The  gauze  is  then  withdrawn  through 
the  vagina.  In  septic  or  suspected  septic  cases  many  prefer  to  leave 
in  a  gauze  drain,  and  only  partially  close  the  vagina. 

(c)  Retention  of  the  Uterus  without  Sterilization  — ■  Conservative 
Cesarean  Section. — This  is  the  ideal  operation.  It  is  carried  out 
as  follows :  After  the  placenta  and  membranes  have  been  care- 
fully removed  from  the  uterus — this  must  be  done  very  completely 
— the  organ  is  grasped  by  the  assistant  as  represented  in  the  illus- 


424 


M'KKATIYK  MlDWIFKliY 


tration  (Fig.  1!)7).  I  have  tried  other  methods  of  holding  the 
uterus  while  the  sutures  are  being  inserted,  and  these  other  methods 
are  shown  (Figs.  198  and  199);  hut  they  are  not  so  satisfactory,  for 
they  prevent  the  escape  of  blood  into  the  vagina.  The  application  of 
a  tourniquet  round  the  cervix  to  control  haemorrhage  is,  I  think, 
undesirable,  as  it  has  a  paralysing  effect  upon  the  uterine  muscle.  It 
is  true  the  method  I  have  indicated  as  being  the  best  is  rather  irksome 
for  the  assistant,  but  with  a  little  practice,  and  by  not  grasping  the 
uterus  too  firmly  at  first,  this  will  be  lessened.     As  may  be  seen  in 


Fio.  198. — Another  Method  of  controlling  Bseniorrhage. 

The  assistant  grasps  the  uterus  and  ovarian  vessels  between  his  thumb  and  fore  and 

middle  fingers. 

the  illustration,  the  assistant  applies  the  thumb  and  forefinger  of 
each  hand  to  the  sides  of  the  incision,  and  brings  the  two  inner  edges 
of  the  wround  exactly  into  apposition  ;  this  is  of  the  very  greatest 
importance,  because,  in  order  to  get  a  firm  cicatrix  in  the  uterus,  the 
stitches  must  be  inserted  through  the  entire  uterine  wall  up  to  the 
m  :cous  membrane  (Fig.  199). 

I  agree  with  the  late  Cullingworth,  Zweifel,  and  Fritsch  that  no 
harm  results  from  stitching  through  the  whole  thickness  of  the  uterine 
wall.  Indeed,  if  the  placenta  has  been  situated  on  the  anterior  wall 
under  the  incision,  I  think  it  is  a  distinct  advantage,  for  in  such  cases 


CESAREAN  SECTION 


125 


the  deeper  portions  of  the  uterine  wound,  heing  occupied  by  large 
sinuses,  are  very  friable ;  consequently,  in  tightening  the  sutures  they 
are  apt  to  tear  through  the  deeper  parts  of  the  wall,  and  only  the 
superficial  parts  are  brought  into  apposition.  The  mistake  is  often 
made  of  only  stitching  the  superficial  layers  of  the  uterine  wound,  and 
unless  one  is  very  careful  this  mistake  is  easily  made,  for  the  internal 
part  is  often  retracted,  and,  the  whole  internal  surface  of  the  uterus 
being  raw,  it  is  difficult  exactly  to  define  the  internal  edges  of  the 


Fig.  199. — The  Uterine  Sutures  inserted. 

It  also  shows  another  method  for  controlling  haemorrhage.  The  assistant  compresses  the 
vessels  against  the  uterus  by  grasping  the  uterus  with  one  hand.  This  method  of 
controlling  haemorrhage  is  practically  the  same  as  the  application  of  a  tourniquet 
round  the  cervix. 

wound.  The  only  possible  objection  to  stitching  through  the  whole 
thickness  of  the  uterus  is  that  a  portion  of  the  suture,  being  situated 
in  the  uterine  cavity,  is  liable  to  become  infected,  and  this  infection 
may  spread  along  the  sutures.  If  infection  of  the  uterus  does  occur, 
however,  it  is  very  questionable  if  the  patient's  chances  would  be  any 
better  had  the  stitches  not  included  the  mucous  membrane. 

For  many  years  I  used  catgut  for  suturing  the  uterus,  but  recently 
I  have  returned  to  fine  silk.  The  reason  I  abandoned  silk  some  years 
ago  was  because  in  septic  cases,  if  the  silk  became  infected,  a  most 
troublesome  sinus  resulted.     Since  I  have  given  up  Cesarean  section 


126 


OPERATIVE  Mii>\\in:n 


in  infective  cases  the  objection  to  the  use  of  silk  has  been  got  over, 
and  so  I  have  returned  to  it  in  this  operation. 

From  eight  to  twelve  sutures  are  usually  required,  and  these  are 
placed  ut  a  distance  of  about  '.  inch  apart  (Fig.  200).  In  addition, 
a  few  tine  superficial  stitches  are  also  inserted  between  the  others, 
wherever  the  edges  of  the  wound  are  not  in  perfect  apposition. 

In  tying  catgut  sutures  a  double  knot  is  always  desirable,  and  the 
superfluous  portion  of  the  suture  must  not  be  cut  off  too  near  the 
knot,  for  the  uterus  being  an  organ  that  does  not  remain  passive,  but 


Fig.  200.— The  Uterine  Sutures  tied. 


is  frequently  contracting  and  retracting,  the  knots  are  apt  to  come 
undone.  This  is  no  theoretical  danger,  for  it  actually  occurred  in  one 
of  my  cases.  This  patient  some  eight  hours  after  the  operation  showed 
signs  of  collapse.  I'nfortunately,  I  could  not  get  to  see  her.  and  those 
who  were  in  charge,  not  appreciating  fully  the  probability  of  internal 
haemorrhage,  did  not  care  to  open  up  the  abdominal  wound.  At  the 
post-mortem  examination  about  40  ounces  of  blood  were  found  in 
the  abdominal  cavity,  and  two  or  three  of  the  catgut  sutures  were 
untied. 

The  uterus  is  now  ready  to  be  replaced  in  the  abdominal  cavity, 
but  prior  to  doing  this  it  is  firmly  compressed  with  warm  swabs,  and 
all  blood-clot,  etc.,   is  removed    from    the   abdominal  cavity.     Such 


CESAREAN  SECTION  427 

debris  is  usually  found  in  front,  of  the  broad  ligaments  in  the 
utero-vesical  pouch,  although  some  may  also  find  its  way  down  into 
Douglas'  pouch.  Having  replaced  the  organ,  the  abdominal  wound  is 
closed. 

The  stitching  of  the  abdominal  wall  in  layers  is,  I  am  convinced, 
the  best  method  of  closing  the  wound.  In  Cesarean  section,  however, 
the  abdominal  parietes  are  sometimes  so  thin  that  this  is  occasionally 
unnecessary.  My  usual  practice  is  to  stitch  in  three  layers.  I  first 
stitch  the  peritoneum  with  a  continuous  catgut  suture,  then  I  place 
silkworm  gut  interrupted  sutures  through  the  whole  thickness  of  the 
abdominal  wall  except  the  peritoneum.  Before  tying  these  latter, 
I  carefully  bring  together  the  rectus  sheath  with  interrupted  catgut 
sutures.  This  careful  closing  of  the  abdominal  wound  takes  ten 
minutes  longer  than  simple  through  and  through  stitching.  It  is, 
however,  worth  the  time  expended  upon  it.  Before  the  wound  is 
closed  it  should  be  washed  with  normal  saline  solution  and  well 
dried. 

After  the  sutures  have  been  tied,  the  wound  is  washed  with  70  per 
cent,  alcohol,  and  a  simple  dressing  of  sterilized  gauze  and  gamgee 
applied.  The  dressing  is  not,  as  a  rule,  changed  until  the  twelfth 
day,  when  the  stitches  are  removed. 

(d)  Retention  of  the  Uterus  and  the  Sterilization  of  the  Patient  bi/ 
Removal  of  a  Portion  of  the  Tubes. — This  method  is  the  one  most 
frequently  employed  when  it  is  deemed  necessary  to  sterilize  the 
patient.  It  has  this  advantage,  that  it  is  an  easier  operation  than 
hysterectomy,  and  consequently  is  specially  suited  for  practitioners 
who  have  not  had  experience  of  abdominal  surgery,  and  who  are 
suddenly  called  upon  to  perform  the  operation  of  Cesarean  section  in 
out-of-the-way  country  districts  and  without  efficient  assistants. 

The  method  adopted  in  the  Glasgow  Maternity  Hospital  is  to  tie 
the  tubes  in  two  places,  and  remove  the  small  portion  between  the 
ligatures.  If  one  is  not  satisfied  with  this  procedure — and  there  are 
a  few  recorded  cases  where  pregnancy  has  followed — it  is  a  simple 
matter  to  cut  and  tie  the  tubes  close  to  the  uterus,  and  bring  a  fold  of 
peritoneum  over  the  uterine  stump  of  the  tube. 

There  is  one  reason  which  may  be  advanced  in  favour  of  this 
method  of  sterilization,  as  here  described,  and  it  is  that  if  at  a  future 
date  the  woman  wishes  to  have  a  chance  of  another  pregnancy  one 
might  perform  abdominal  section,  and  unite  the  two  ends  of  the  tubes 
together  again.  Here  are  two  cases  to  illustrate  what  I  mean :  A 
patient  who  had  been  sterilized  as  described  came  to  me  in  great 
distress  because  her  child  had  died.  I  told  her  that  I  could  do 
nothing  for  her,  but  it  occurred  to  me  afterwards  that  the  procedure 


128  (H'KIIATIYK   Mil  >\\  II  J.UY 

mentioned  might  have  been  suggested  to  her.  Some  months  later 
I  did  suggest  it  to  another  patient  who  had  been  sterilized  and  who 
had  also  lost  her  child,  but  she  would  not  consent  to  the  operation. 
Such  a  procedure  as  I  have  suggested  is  quite  feasible,  provided  one 
simply  cuts  and  ties  the  tubes,  for  in  two  cases  in  which  I  saw  the 
abdomen  opened  some  years  after  because  of  the  presence  of  an 
ovarian  tumour,  the  ends  of  the  tubes  were  patent,  and  could  have 
been  easily  reunited. 

This  is  perhaps  the  most  suitable  place  for  considering  the  question 
of  sterilization  after  Cesarean  section — a  subject  of  great  interest,  and 
regarding  which  very  different  views  are  held  at  present.  With  regard 
to  this  subject  there  appears  to  me  to  be  three  matters  for  considera- 
tion :  (1)  The  ethical  question ;  (2)  the  danger  to  the  patient  of  the 
repetition  of  the  operation ;  (8)  the  danger  of  rupture  of  the  uterus 
during  a  subsequent  pregnancy. 

From  the  ethical  standpoint  the  question  of  sterilization  is  a  very 
subtle  and  difficult  one.  A  most  interesting  discussion  on  the  subject 
took  place  at  a  meeting  of  the  American  Gynaecological  Society.1  It 
followed  the  reading  of  a  paper  by  Green  on  '  Eepetition  of  Cesarean 
Section  on  the  same  Patient :  the  Experience  at  Boston  Lying-in 
Hospital.'  Green  took  up  a  very  strong  position,  a3  can  be  judged 
from  the  following  quotation  :  '  I  venture  to  assert  that  the  only  safe 
and  moral  ground  for  the  medical  profession  is  that  based  upon 
modern  medical  science  uninfluenced  by  sociological  considerations. 
If  a  woman  comes  to  Cesarean  section  and  recovers,  she  and  her 
husband,  if  she  has  one,  should  be  informed  of  her  condition,  and  of 
the  prognosis  and  treatment  in  the  event  of  future  pregnancy  ;  if 
subsequent  pregnancy  ensues,  the  responsibility  of  treatment  rests 
with  the  obstetric  surgeon,  but  the  responsibility  for  the  condition 
rests  elsewhere.' 

In  the  same  discussion,  Whitridge  Williams  distinguished  between 
'pauper  patients'  and  'women  in  the  upper  walks  of  life.'  As 
regards  the  former,  he  is  reported  to  have  said :  '  I  do  not  believe  we 
are  justified  in  allowing  pauper  patients  to  be  subjected  to  repeated 
Cesarean  section  unless  they  particularly  desire  it.'  As  regards  the 
others,  he  continued  :  '  They  should  be  made  to  share  the  responsi- 
bility with  the  physician.  In  such  cases  the  husband  and  wife  have 
the  right  to  demand  sterilization,  though  I  should  earnestly  dissuade 
them  from  it  after  the  first  operation,  and  point  out  to  them  the 
possibility  of  the  subsequent  death  of  the  child  and  the  absolute 
impossibility  of  having  another  after  such  an  operation.  If,  however, 
the  patient  requires  a  second  operation,  the   matter  should  be  left 

1  Trans.  Ainer.  Gyn.  Soc,  1903,  vol.  xxviii.,  p.  128. 


CESAREAN  SECTION  429' 

almost  entirely  in  her  hands  ;  but  my  advice  would  tend  in  the  direc- 
tion of  rendering  her  sterile  at  that  time,  as,  no  matter  how  favour- 
able our  results  may  be,  an  occasional  death  is  bound  to  occur. 

A  similar  discussion  followed  a  paper  read  by  me  before  the 
London  Obstetrical  Society.1  Spencer,  who  has  for  many  years  con- 
sistently recommended  the  conservative  operation,  said :  '  The  matter 
was  an  ethical  one,  to  be  decided  entirely  by  the  doctor,  and  that  his 
duty  was  to  deliver  the  woman  and  restore  her  as  nearly  as  possible 
to  a  natural  condition,  a  result  obtained  by  the  conservative  operation 
without  sterilization,  and  not  by  the  mutilating  operation  of  hyster- 
ectomy, nor  by  the  unreliable  and  dangerous  one  of  tying  the  tubes. 
If  the  patient  became  pregnant  again,  the  responsibility  was  not  the 
doctor's,  whose  duty  was  to  repeat  the  Cesarean  section,  which 
experience  had  shown  to  be  very  safe.' 

Herman,  on  the  other  hand,  is  reported  to  have  said  :  '  It  was  for 
the  patient  to  decide  whether  she  would  be  sterilized  or  not.'  Culling- 
worth  sided  with  Spencer,  and  Routh  with  Herman. 

The  danger  of  repeated  Cesarean  section  was  gone  into  very  fully 
by  Wallace2  some  years  ago.  Since  his  contribution  many  cases  have 
been  reported,  and  the  mortality  has  fallen  to  a  very  low  figure.  It 
has  fallen  below  the  mortality  of  Cesarean  section  performed  for  the 
first  time.  This  is  to  be  accounted  for  in  several  ways.  The  chief 
reason  is  that  if  the  operation  is  to  be  repeated  the  woman  is  watched 
carefully  during  the  later  weeks  of  her  pregnancy  and  is  taken  into 
hospital  or  private  home  before  labour  is  expected,  and  so  is  well  pre- 
pared for  the  repeated  operation. 

Another  reason  given  for  the  lower  mortality  is  the  presence  of 
extensive  adhesions,  which,  it  is  claimed,  shut  off  the  general  peritoneal 
cavity  so  that  the  uterus  may  be  evacuated  without  opening  into  the 
general  peritoneal  cavity.  Now,  while  I  admit  that  adhesions  are 
often  found  at  a  subsequent  operation,  they  are  rarely  so  extensive  as 
to  permit  of  the  second  operation  being  performed  outside  the  general 
peritoneal  cavity.  I  have  performed  the  operation  twice  on  the  same 
patient  upon  nine  occasions,  and  in  another  case  I  have  had  to  open 
the  abdomen  because  of  the  rupture  through  the  cicatrix  of  a  previous 
Cesarean  section  wound  in  a  woman  who  had  nearly  reached  term. 
In  the  latter  case  there  were  absolutely  no  adhesions.  In  only  two 
would  it  have  been  possible  to  open  the  uterus  without  opening  the 
peritoneal  cavity.  Naturally,  with  each  operation  the  adhesions 
between  uterus  and  abdominal  parietes  become  more  intimate. 

It  has  been  my  practice,  up  to  the  present,  to  sterilize  the  woman 

1  Trans.  Lond.  Obst.  Soc,  1905,  vol.  xlvi.,  p.  309. 

2  Journ.  Obst.  and  Gyn.  Brit.  Empire,  December,  1902. 


180  OPERATIVE  MIDWIFER1 

after  a  second  Cesarean  section,  either  by  tying  the  tubes  or,  more 
generally,  by  removing  the  uterus.  I  have  made  an  exception  to  this 
rule  in  two  cases.  I  find  myself  in  agreement,  therefore,  with  Whit- 
ridge  Williams,  for  I  feel  that  a  woman  who  has  twice  subjected  her- 
self to  Cesarean  section  has  done  sufficient  for  her  family  and  the 
State.  Others,  however,  have  acted  differently,  and  have  repeated 
the  operation  three,  four,  five,  and  even  seven  times.  I  do  not  say 
that  I  will  not  ultimately  follow  their  example,  but  at  present  I  am 
not  convinced  it  is  the  right  treatment. 

The  danger  of  the  uterine  cicatrix  giving  way  at  a  subsequent 
pregnancy  or  parturition  is  the  chief  argument  advanced  by  those  who 
are  opposed  to  the  conservative  operation.  Relatively  speaking,  there 
is  a  fair  proportion  of  cases  in  which  rupture  has  occurred.  For 
example,  ruptures  have  been  recorded  by  myself,1  Guillaume,-  Kob- 
lanck,:J  Woyer,4  Target,5  Galabin,0  Everke,7  Meyer,"  Eckstein,9 
Prusmann,10  Convelaire,11  Werth,12  and  a  few  others.  The  most 
important  monograph  on  this  subject  is  by  Singer. 1:; 

In  connexion  with  these  cases,  it  is  an  interesting  fact  that  in  a 
large  proportion  the  placenta  was  situated  over  the  cicatrix  of  the 
previous  Cesarean  section  wound. 

Without  doubt,  in  many  cases  the  rupture  has  resulted  from  imper- 
fect suturing  of  the  uterine  wound.  As  I  have  already  pointed  out, 
this  mistake  is  very  easily  made,  for  the  inner  part  of  the  wound  tends 
to  retract,  and  so  the  two  surfaces  are  not  completely  and  exactly 
brought  together.  But  there  is  another  factor  no  less  important- 
viz..  infection  of  the  wound.  It  is  of  prime  importance,  therefore, 
that  the  wound  is  most  carefully  stitched  and  heals  by  first  intention, 
if  the  conservative  operation  is  employed. 

Results  to  Mother  and  Child. 

As  regards  the  results  to  mother  and  child  from  Cesarean  section, 
I  shall  only  consider  cases  of  contracted  pelvis,  for  one  can  hardly 
estimate  the  mortality  from  the  operation  in  cases  of  eclampsia, 
accidental  haemorrhage,  etc. 

Taking  my  own  results,  I  and  my  assistants  have  performed  the 

1  Journ.  Olst.  and  Gyn.  Brit.  Empire,  November,  1904. 

2  Zent.  f,  Gyn.,  1896,  p.  1286.  3  '  Uterus  Bupture,'  1896. 
4  Monat.f.  Gel.  u.  Gyn.,  1897,  Bd.  vL,  p.  192. 

"J  Trans.  Lond.  Obst.  Soc,  vol.  \lii.,  1900,  p.  262.  ,;   Ibid.,  p.  248. 

7  Monat.  f.  < i<'li.  a.  Gyn.,  1901,  Bd.  xiv.,  p.  637. 

a  Zent.f.  Gyn.,  L903,  p.  1416.  '■'  Ibid..  1904,  p.  1802. 

111  Zentf.  (lib.  a.  Gyn.,  1905,  Bd.  lv.,  p.  415. 

11  Zent.  de  Gyn.,  1906,  p.  148.  12  Zent.f.  Gyn.,  1D00.  p.  565. 

13  '  Des  Cicatrices  Cesariennes  Abdonrinales  Classiques,'  Paris,  1909. 


CESAREAN  SECTION 


431 


operation  eighty  times.  Seven  of  the  mothers  died — a  maternal 
mortality  of  8'7  per  cent.  One  of  the  deaths  I  have  already  referred 
to:  it  resulted  from  haemorrhage.  The  sutures  of  the  uterine  wound 
came  undone.  Another  resulted  from  acute  pneumonia  on  the  fourth 
day  after  operation.  A  large  window  in  the  ward  in  which  she  was 
placed  was  blown  in,  and  she  was  transferred  to  another  ward.  A  few 
hours  after  she  had  a  rigor.     The  other  five  died  from  sepsis. 

The  results  of  Continental  operators  are  very  similar.  Olshausen1 
for  91  cases  had  a  mortality  of  9"8  per  cent.;  Schauta2  for  158  cases 
a  mortality  of  5  per  cent.  ;  and  Leopold"'  for  188  cases  a  mortality  of 
7*5  per  cent. 

Some  particularly  good  results  have  been  obtained  in  this  country, 
notably,  by  Gow,  Barber,  and  Russell. 

But  much  more  important  than  the  bare  narration  of  percentage 
mortalities  are  the  results  obtained  from  the  operation  performed 
under  different  conditions.  This  aspect  of  the  subject  has  been  gone 
into  most  fully  by  Amand  Routh.4  One  of  the  most  interesting  tables 
in  his  monograph  is  Table  IV.  (p.  48) : 

Table  showing  the  Mortality  of  Cesarean  Operations  for  Contracted  Pelvis 
where  Details  are  given  as  to  Possible  Infectivity  (1901-1910). 


Condition. 

Cases. 

Maternal 
Deaths. 

Percentage. 

A.  Not  in  labour           ...         ...         ...  i     245).™ 

B.  In  labour,  membranes  unruptured         224/ 

C.  In  labour,  membranes  ruptured  ...        1661 

D.  Frequent  examinations  or  attempts               -230 

at  delivery            ...         ...         ...          64 j 

18  | 

Uo 
22J 

11}  ™ 

10-8) 

-173 
34-3J 

These  figures  demonstrate  conclusively  that  Cesarean  section  per- 
formed upon  women  '  when  frequent  examinations  or  attempts  at 
delivery  have  been  made  '  is  a  most  dangerous  operation  for  the 
mother.  That  being  admitted,  let  us  consider  what  are  the  alterna- 
tives :  (1)  Craniotomy  —  this  treatment  has  been  fully  considered; 
(2)  Extraperitoneal  Cesarean  Section.  During  the  last  two  years 
much  has  been  written  on  this  subject  in  the  German  obstetrical 
journals.  The  history  of  the  evolution  and  development  of  the  opera- 
tion will  be  found  in  such  monographs  as  those  of  Jeannin5  and 
Doderlein.6     But  it  is  quite  impossible  to  consider  this  aspect  of  the 

1  Zent.fiir  Gxjn.,  1906. 

2  Neumann,  Arcliiv  filr  Gyn.,  1906,  Bd.  lxxix.,  Heft  1,  p.  1. 

3  Arcliiv  fiir  Gyn.,  1907,  Bd.  lxxxi.,  Heft  1. 

4  Jov/rn.  Obst.  and  Gyn.  Brit.  Empire,  January,  1911. 
6  L'Obstetrique,  August,  1909. 

6  Monat.  f.  Geb.  u.  Gyn.,  January,  1911. 


182  OPERATIVE  Mii'W  mt:i;y 

subject  here.  As  far  a-  my  personal  reading  goes  (I  have  no  practical 
experience  of  the  operation),  the  best  procedure  is  that  recommended 
by  Doderlein.1  This  is  really  a  modification  of  Latzko'e  operation, 
hoderlein,  instead  of  employing  a  Phannen.-teil's  incision,  makes  an 
inciBion  parallel  to  1'oupart's  ligament  from  the  symphysis  pubis  to 
the  anterior  superior  spine.  He  cuts  through  skin,  fascia,  and  muscles, 
securing  and  tying  any  bleeding  vessels.  Having  reached  the  lower 
cellular  tissue,  he  pushes  it  aside  and  defines  the  lateral  limit  of 
attachment  of  the  bladder,  which  he  pushes  over  towards  the  middle 
line.  The  lower  limit  of  peritoneum  is  not  observed.  He  then  renders 
the  surface  of  the  uterus  (lower  segment)  clear  by  separating  off  the 
loose  cellular  tissue  and  securing  any  bleeding  vessels.  Having  done 
this,  he  makes  an  incision  into  the  uterus  two  fingers'  breadth  from 
the  margin  of  the  bladder.  The  child  is  extracted  with  forceps  if  the 
head  is  the  presenting  part,  or  by  traction  on  the  limbs  if  the  breech 
presents.  The  placenta  is  expressed  or  removed  by  hand.  The 
stitching  of  the  uterine  wound  is  very  simple  as  the  wall  is  so  thin. 
A  continuous  catgut  suture  is  employed.  Doderlein  employs  a  second 
layer  of  continuous  suture,  by  means  of  which  he  brings  some  cellular 
tissue  over  the  wound.  He  then  closes  the  abdominal  wound,  having 
previously  inserted  a  drain  into  the  cellular  tissue.  Personally,  I  very 
much  doubt  if  this  method  of  extraperitoneal  section  will  ever  meet 
with  much  support,  and  this  for  several  reasons  :  (1)  It  is  a  much  more 
complicated  operation.  (2)  It  has  not  been  proved  that  the  maternal 
mortality  is  lower  in  infected  or  possibly  infected  cases.  (3)  It  has 
not  been  proved  that  the  uterine  cicatrix,  after  this  operation,  is 
stronger  than  the  cicatrix  after  the  ordinary  longitudinal  incision.  I 
I  feel  convinced  that  extraperitoneal  Cesarean  section  will  never  give 
better  results  than  the  ordinary  operation  in  infected  cases,  but  I  can 
imagine  that  there  is  a  possibility  that  the  uterine  cicatrix  may  be 
sounder  when  made  in  the  lower  segment  than  on  the  active  con- 
tractile portion  of  the  uterus.  If  the  advocates  of  this  operation 
can  prove  that  to  be  the  case,  then  I  will  at  once  become  a  convert 
to  the  extraperitoneal  section.  (4)  It  has  been  suggested  by  Sellheim 
to  establish  a  utero  -  abdominal  fistula  for  drainage  purposes,  but 
few  favour  such  a  procedure.  (5)  Total  or  sub-total  hysterectomy 
is  certainly  the  soundest  procedure ;  but  if  the  woman  is  young, 
it  is  surely  a  most  unfortunate  proceeding  to  remove  her  uterus. 
(6)  Improvement  in  the  technique  of  the  operation.  This  is  merely  a 
personal  suggestion.  In  these  infected  or  '  suspect '  cases,  I  feel  sure 
the  uterus  is  often  infected  by  dragging  up  the  placenta,  and  more 
particularly  the  ruptured  membranes,  through  the  uterine  wound.  I 
1  Monat.  f.  Oeb.  n.  Oyn.t  January,  1911. 


CESAREAN  SECTION  433 

would  suggest  that  in  all  cases,  where  the  labour  is  advanced,  and 
especially  in  possibly  infected  cases,  the  operator,  after  removing  the 
child,  should  put  on  fresh  gloves  and  separate  the  placenta ;  and, 
instead  of  removing  it  by  the  wound,  should  push  it  down  through  the 
cervix.  It  might  be  quite  useful  to  fasten  the  end  of  the  roll  of  gauze 
to  the  umbilical  cord  and  push  the  gauze  down  into  the  vagina,  and 
by  means  of  it  drag  the  placenta  out  of  the  vagina.  I  have  only 
carried  out  this  procedure  in  two  cases,  but  I  believe  that,  with  a  high 
uterine  incision  and  this  suggested  method  of  removing  the  placenta, 
it  is  possible  that  better  results  might  be  obtained,  and  the  uterus 
might  be  saved. 

Post-mortem  Caesarean  Section. 

The  performance  of  Cesarean  section  upon  women  who  die  during 
parturition  or  late  in  pregnancy  is  an  operation  of  great  antiquity  ; 
indeed,  its  beginning  is  lost  in  mythology.  According  to  the  Lex 
Regia  instituted  by  Numa  Pompilius,  it  was  decreed  that  the  opera- 
tion was  to  be  performed  should  the  mother  die  during  the  later 
weeks  of  pregnancy  or  parturition.  From  the  very  earliest  times, 
therefore,  it  has  been  appreciated  that  an  attempt  should  be  made  to 
save  the  child,  provided  the  child  is  viable,  in  all  cases  where  the 
mother  dies. 

Owing  to  the  fact  that,  comparatively  speaking,  so  few  children 
are  saved  by  post-mortem  Cesarean  section,  it  has  been  recommended 
at  different  times  that  the  operation  should  be  performed  before  the 
death  of  the  mother  actually  occurs.  According  to  Fasbender,  this 
was  first  mentioned  by  Rodericus  a  Castro  in  1603.  The  operation 
upon  the  dying  has  always  been  so  repugnant,  however,  to  both  the 
friends  and  medical  attendants  that  it  has  been  performed  com- 
paratively seldom.  Apart  from  sentiment,  there  is  everything  to  be 
said  in  its  favour,  so  that  it  is  not  surprising  that  from  time  to  time 
it  should  have  been  advocated.  Kleinhans,1  who  discusses  the  subject 
very  fairly,  gives  the  following  as  the  conditions  which  must  be  fulfilled 
before  an  operation  is  proceeded  with  : 

1.  '  The  death  of  the  pregnant  woman  must  be  imminent.  It  is 
essential  that  several  doctors  give  a  unanimous  verdict  to  that 
effect. 

2.  '  There  must  be  proof  that  the  child  is  alive.  Here  also  it  is 
essential  to  have  the  examination  and  opinion  of  several  doctors. 

3.  '  The  Cassarean  section,  which  is  quickest  and  least  dangerous 
for  the  child,  is  the  operation  indicated.' 

1  Winckel's  '  Handbuch,'  1906,  Bel.  iii.,  Teil  i.,  p.  844. 

28 


[84  0PE1IATIVK  MIDWIFF.KY 

Two  comparatively  recent  papers  on  fche  subject  are  those  by 
I  ►ohrn1  and  Fiith.'-' 

ln  recent  years  ;i  aumber  of  children  have  been  saved  by  post- 
mortem Csesarean  section,  and  that,  too,  after  a  considerable  interval 
from  the  death  of  the  mother.  For  instance.  Weisswange  described 
a  case  where  the  child  was  delivered  alive  nineteen  minutes  after  the 
death  of  the  mother. 

Very  valuable  experiments  on  rabbits  were  made  by  Kunge4  many 
years  ago. 

My  own  experience  of  post-mortem  Cesarean  section  is  limited  to 
two  cases — one  done  by  an  assistant  in  hospital,  and  the  other  by  the 
practitioner  who  called  me  to  the  case  in  consultation.  Neither  of 
the  children  were  saved,  although  in  the  latter  case,  where  the  mother 
died  of  heart  disease,  the  child's  heart  was  still  beating  feebly  when  it 
was  extracted. 

As  one  would  expect,  the  cases  in  which  there  is  the  greatest 
chance  of  saving  the  child  are  where  the  mother  dies  suddenly,  and 
the  operation  is  performed  immediately. 

1  Samml.  Klin.  Vortrdge,  1900,  No.  274. 

2  Zcnt.f.  Gyn.,  1905,  p.  714.  3  Ibid.,  1903,  p.  298. 
4  Zeit.f.  Geb.  u.  Gyn.,  Bd.  ix.,  Heft  2. 


CHAPTER  XXVII 

INDUCTION  OF  PREMATURE  LABOUR 

To  whom  belongs  the  honour  of  first  suggesting  the  operation  of 
induction  of  premature  labour  is  uncertain,  and  the  difficulty  of  dis- 
covering this  is  rendered  all  the  greater  by  the  fact  that  induction  of 
abortion  for  grave  conditions  threatening  the  mother  was  performed 
in  very  early  times.  But  from  the  beginning  of  the  Christian  era, 
discouraged  by  the  Church,  it  ceased  to  be  practised  almost  entirely 
amongst  Christian  peoples. 

With  the  revival  in  midwifery,  and  the  placing  of  the  latter  once 
again  upon  a  scientific  basis  by  Pare  and  his  pupils,  artificial  inter- 
ruption of  pregnancy  for  conditions  threatening  the  mother  came  to 
be  recommended.  For  example,  in  certain  severe  cases  of  haBinor- 
rhage  Guillemeau  recommended  and  practised  emptying  the  uterus. 
Earlier  than  that,  even,  we  have  in  Germany  the  distinguished  mid- 
wife Siegemundin  recommending  rupture  of  the  membranes  through 
the  placenta  in  placenta  prama.  For  other  complications,  such  as 
valvular  disease  of  the  heart,  nephritis,  etc.,  the  operation  is  of  recent 
date. 

But  there  is  a  condition  which  interests  us  above  all  others,  as 
furnishing  an  indication  for  the  induction  of  premature  labour — viz., 
a  medium  degree  of  pelvic  deformity.  The  history  of  the  operation  in 
this  connexion  is  well  known.  In  the  year  1756  there  was  a  meeting 
in  London  of  the  most  distinguished  obstetricians  of  the  day  to 
discuss  the  morality  of  induction  of  premature  labour  in  contracted 
pelvis.  The  finding  of  the  meeting  was  in  favour  of  the  operation, 
and  shortly  afterwards  Macaulay  performed  it  for  the  first  time. 
Doubtless  it  had  been  talked  about  prior  to  that  gathering,  not  only 
in  Great  Britain,  but  also  in  France,  Germany,  and  Italy.  Be  that 
as  it  may,  it  was  first  performed  in  Great  Britain,  and,  what  is  more, 
for  many  years  it  was  only  in  our  country  that  it  was  practised.  In 
France,  owing  to  the  opposition  chiefly  of  Baudelocque,  the  treatment 
was  condemned  ;  and  so  strong  was  his  and  his  pupils'  antagonism 

435 


186  OPERATIVE  M1I>YYI1T.I;Y 

that  it  was  not  until  1881  that  it  was  performed  there.     In  Germany 
it  was  accepted  earlier,  for  Wenzel  performed  it  in  1809. 

Indications  for  Induction  of  Premature  Labour. 

What  strikes  one  in  reading  the  literature  on  this  subject  is  the 
greal  differences  of  opinion  held  by  obstetricians,  especially  the  extreme 
position  so  many  of  them  take  up  with  regard  to  each  of  the  several 
indications,  and  how  often  apparent  inconsistency  is  evidenced,  extreme 
licence  being  allowed  in  one  condition,  and  equally  extreme  restrictions 
being  laid  down  in  another. 

The  indications  for  induction  of  premature  labour  or  abortion  may, 
for  convenience'  sake,  be  divided  into  obstetrical  and  medical.  Tnder 
obstetrical  I  would  place  all  pathological  conditions  in  the  mother 
or  child  which  render  delivery  at  term  dangerous,  or  necessitate  the 
adoption  of  an  operation  of  greater  seriousness  than  the  one  we  are 
considering.  Thus,  in  this  group  I  place  contracted  pelvis  and  undue 
size  of  the  fcetus.  It  will  be  observed  that  I  have  not  included  con- 
tractions and  malformations  of  the  soft  parts,  nor  tumours  of  the 
uterus,  ovary,  etc.,  for  all  accoucheurs  are  agreed  that  induction  of 
labour  in  such  conditions  is  rarely,  if  ever,  advisable. 

But  let  us  consider  the  medical  indications  first.  These  I  would 
say  are  conditions  in  which,  owing  to  disease,  it  is  felt  that  the 
pregnant  condition  is  endangering  the  life  of  the  mother  or  child. 
On  the  maternal  side  there  are  in  this  division  an  enormous  number 
of  diseases,  but  they  may  be  arranged  in  three  groups:  (1)  Acute 
diseases  occurring  during  pregnancy ;  (2)  chronic  diseases  associated 
with  pregnancy  ;  (3)  diseases  peculiar  to  pregnancy. 

On  the  fcetal  side,  its  habitual  death  in  the  later  weeks  of  preg- 
nancy, and  the  protraction  of  pregnancy  beyond  the  normal  ten  lunar 
months  and  unusual  size  of  the  fcetus  are  the  conditions  which  call  for 
consideration. 

1.  Acute  Diseases  occurring-  during:  Pregnancy. — The  induction 
of  premature  labour  or  abortion  is  almost  never  indicated  in  acute  febrile 
conditions.  Doubtless,  in  many  of  these  acute  diseases,  especially  if 
the  type  is  severe  and  the  temperature  runs  high,  an  early  induction 
of  labour  would  result  in  some  children  being  saved,  but  it  would  also 
with  equal  certainty  be  followed  by  a  higher  maternal  mortality.  It 
is,  therefore,  the  universal  opinion  of  both  physicians  and  obstetricians 
that  the  interfering  with  pregnancy,  except  in  most  exceptional  cir- 
cumstances, is  decidedly  contra-indicated.  But  it  is  just  regarding 
these  exceptional  circumstances  that  an  opinion  is  desirable.  Speaking 
in  a  very  general  way,  I  would  say  that  induction  of  labour  is  indicated 
under  the  following  circumstances — if  with  a  dead  child  in  utero  there 


INDUCTION  OF  PREMATURE  LABOUR  437 

is  evidence  of  septic  absorption  occurring  from  it.  This,  of  course, 
is  very  rare  if  the  membranes  are  intact ;  indeed,  as  far  as  I  can 
remember,  I  have  seen  only  one  case.  Again,  if  the  size  of  the  dis- 
tended uterus  is  interfering  with  the  cardiac  and  respiratory  functions, 
the  operation  must  be  considered.  In  this  connexion,  however,  it 
must  not  be  forgotten  that  a  labour  puts  a  very  severe  strain  upon 
a  heart  embarrassed  by  an  acute  febrile  condition,  especially  if  one 
forcibly  dilates  the  cervix.  In  such  cases,  therefore — and  they  must 
be  very  few  in  which  labour  has  to  be  induced — I  feel  inclined  to 
favour  the  more  rapid  method  of  emptying  the  uterus  by  incising  the 
■cervix.  Should  the  woman  not  be  able  to  stand  such  an  operation, 
simple  rupture  of  the  membranes  might  give  partial  relief. 

There  is  one  other  matter  which  comes  for  consideration  here.  In 
the  case  of  a  viable  child,  should  labour  be  induced  in  the  interests  of 
the  child  if  the  mother  is  evidently  dying  ?  It  is  hardly  necessary  to 
say  that  it  is  extremely  trying  to  an  operator's  feelings  and  senti- 
ments to  operate  upon  a  dying  woman  when  he  is  not  performing  the 
operation  in  her  interests.  In  spite  of  that,  however,  I  think  it  is 
his  duty  to  do  the  best  for  the  child,  and  consequently  to  empty  the 
uterus  before  the  mother's  death  rather  than  wait  and  do  it  post 
mortem,  when  there  will  be  very  little  chance  of  saving  the  child. 
This  same  question  was  also  considered  in  connexion  with  Cesarean 
section  on  the  dying  (Chapter  XXVI.). 

It  is  hardly  necessary  to  say  that  acute  conditions  such  as 
appendicitis  and  intestinal  obstruction  must  be  dealt  with  in  exactly 
the  same  way  in  the  pregnant  as  in  the  non-pregnant.  One  would 
never  think  of  inducing  labour  in  such  conditions. 

2.  Chronic  Diseases  complicated  by  Pregnancy. — As  might  be 
expected,  induction  of  labour  or  abortion  is  more  often  called  for  in 
cases  belonging  to  this  group.  But  while  that  is  so,  we  find  great 
differences  of  opinion  amongst  writers  regarding  the  indications  for 
such  radical  treatment.  In  the  next  group  to  be  considered,  'diseases 
peculiar  to  the  pregnant  condition,'  we  shall  find  much  greater 
uniformity  of  opinion,  for  there  labour  is  induced  when  all  other 
means  fail  to  arrest  the  downward  progress  of  the  patient.  With 
chronic  diseases,  however,  the  same  downward  progress  is  not  as 
easily  appreciated,  and  so  the  difficulty  of  deciding  is  greater,  and 
•taxes  more  the  operator's  judgment. 

The  chronic  diseases  most  commonly  found  associated  with  preg- 
nancy are  renal  cirrhosis  and  valvular  disease  of  the  heart.  Although 
it  is  universally  agreed  that  neither  of  these  conditions  per  se  is  a 
sufficient  indication  for  the  induction  of  either  premature  labour  or 
abortion,  with  each  of  them  the  operation  may  be  necessary,  when,  in 


188  <>n:i:.\T!\  k  mii>\\  n  r.i;v 

spite  of  the  ordinary  treatment,  rest  in  bed.  dieting,  and  the  adminis- 
tration of  suitable  drugs,  the  patient's  condition  does  not  sufficiently 
improve.  With  chronic  nephritis  one  is  inclined  to  interfere  earlier, 
and  not  to  give  the  child  so  much  consideration,  seeing  that  its  life  i- 
80  very  precarious  and  its  death  and  premature  expulsion  so  frequent. 
Therefore,  when  pronounced  symptoms,  such  as  severe  headache, 
disturbance  of  vision,  etc.,  develop  in  spite  of  treatment,  labour  should 
be  induced  without  delay.  Even  prior  to  these  symptoms  developing 
a  progressive  diminution  in  the  quantity  of  urine  and  in  the  output  of 
urea  call  for  the  operation. 

In  this  connexion  must  be  mentioned  '  retinitis  albuminuria/ 
which  in  the  chronic  variety  is  a  serious  complication.  1  understand, 
however,  that  the  prognosis  from  the  ophthalrnological  point  of  view 
is  very  good  in  such  cases,  and  that  induction  of  labour  is  seldom 
necessary  on  account  of  any  permanent  damage  to  vision  resulting. 

As  regards  chronic  valvular  disease  of  the  heart  it  is  different,  for 
in  that  condition  there  is  a  great  danger  during  and  after  parturition 
of  pronounced  cardiac  failure.  I  have  several  times  induced  labour 
for  cardiac  disease,  but  always  with  considerable  anxiety,  for  although 
the  patients,  with  one  exception,  have  stood  the  labour  well,  one  or 
two  have  died  a  few  days  later.  Often  for  the  first  twenty-four  or 
thirty-six  hours  in  such  cases  there  is  marked  improvement,  to  be 
followed  in  a  few  days  by  an  aggravation  of  all  the  symptoms  of 
cardiac  failure,  which  steadily  increases  in  spite  of  all  one's  efforts  to 
arrest  it.  I  am,  therefore,  very  loath  to  induce  labour  in  valvular 
disease,  unless  I  am  compelled  to  do  so  owing  to  the  patient  becoming 
steadily  worse  in  spite  of  treatment.  Most  recent  obstetric  writers  of 
experience  are  also  of  this  opinion.  Many  of  them  refer  to  the  greater 
safety  of  emptying  the  uterus  in  the  early  months,  and  I  am  at  one 
with  them  in  that. 

It  is  an  advantage  in  this  condition  to  empty  the  uterus  rapidly, 
with  as  little  shock  as  possible  to  the  patient.  Consequently,  this  is 
distinctly  one  of  the  conditions  in  which  I  believe  vaginal  Cesarean 
section  has  a  place. 

In  recent  years  several  monographs  have  appeared  on  the  various 
anaemias  and  other  blood  diseases  in  pregnancy,  and  the  indications 
for  the  induction  of  premature  labour  in  such  conditions  have  been 
fully  discussed.  Herman,1  for  example,  considered  leukaemia  and 
pregnancy,  and  came  to  the  conclusion  '  that  in  leukaemia  with  preg- 
nancy the  induction  of  premature  labour  or  abortion  is  indicated  as  a 
therapeutic  measure.'  Many  years  ago  Gusserow  and  Graefe  referred 
to  the  great  danger  of  pregnancy  in  women  the  subjects  of  pernicious 
1  Trans.  Lond.  Obst.  Soc,  1901. 


INDUCTION  OF  PREMATURE  LABOUR  439 

anemia.     Recently,  however,  Schauta  has  insisted  that  little  benefit 
results  from  emptying  the  uterus  in  these  cases. 

Another  disease  which,  along  with  others,  I  have  found  very 
seriously  aggravated  by  pregnancy  is  Graves'  disease,  and  I  certainly 
agree  with  those  who  would  induce  labour  if  this  complication  is  pro- 
nounced, particularly  as  the  disease  is  very  intractable  after  pregnancy. 
Williamson1  has  recorded  a  case  where  labour  or  abortion  was  induced 
four  times.  Many  obstetricians  have  been  disappointed,  however, 
with  the  benefit  derived  from  emptying  the  uterus. 

Chorea  gravidarum  is  another  condition  which  occasionally  necessi- 
tates the  operation.  Amongst  the  most  valuable  contributions  in  the 
English  language  are  those  of  Buist,2  Dyce  Duckworth,3  Wall  and 
Andrews,4  and  Shand.5  With  the  exception  of  Wall  and  Andrews, 
Shand,  and  a  few  others,  most  authorities  are  agreed  that  induction 
of  labour  should  be  resorted  to  when  the  movements  are  extremely 
violent,  and  are  uninfluenced  by  treatment,  and  when  extreme  sleep- 
lessness, and  especially  mania,  supervene.  In  this  disease,  as  in 
others  presently  to  be  considered,  the  operation  must  not  be  too  long 
delayed,  a  mistake  which  is  so  often  made. 

3.  Diseases  Peculiar  to  Pregnancy. — The  large  proportion  of 
such  diseases  are  toxaemias,  and  one  can  generalize  to  this  extent,  and 
say  that  the  induction  of  labour  or  abortion  becomes  necessary  if,  in 
spite  of  treatment,  the  patient  steadily  loses  ground  and  her  life  is 
seriously  endangered.  The  usual  mistake  in  practice  is  for  the 
medical  attendant  to  postpone  the  operation  too  long.  This  is 
especially  the  case  with  hyperemesis,  the  most  common  of  all  the 
conditions  calling  for  this  radical  treatment.  It  is  quite  impossible 
to  lay  down  hard-and-fast  rules  as  to  when  abortion  should  be 
induced  in  hyperemesis.  If,  however,  after  general  and  local  treat- 
ment, and  complete  rest  to  the  stomach  by  rectal  feeding,  the  retching 
continues,  or  returns  whenever  any  food  is  taken  by  the  mouth, 
and  if  the  pulse  becomes  progressively  more  rapid,  the  time  for 
emptying  the  uterus  has  arrived.  Pinard  is  more  definite,  and  relies 
chiefly  upon  the  pulse,  and  recommends  induction  if  it  rises  above  100. 
But  such  a  simple  and  exact  rule  cannot  be  followed.  How  far  the 
increase  in  the  '  ammonia  coefficient '  (percentage  of  nitrogen  put  out 
as  ammonia  compared  with  the  total  nitrogen  of  the  urine)  is  of  value 
as  indicating  the  seriousness  of  the  condition  one  cannot  at  present 
say,  but  Williams6  believes  10  per  cent,  indicates  danger. 

1  Trans.  Lond.  Obst.  Soc,  1904,  p.  95.  2  Trans.  Edin.  Obst.  Soc,  vol.  xx. 

3  St.  Bartholomew's  Hospital  Reports,  1903. 

4  Journ.  Obst.  and  Gyn.  Brit.  Empire,  June,  1903. 

5  Ibid.,  April,  1907. 

6  Amer.  Journ.  Med.  Sciences,  September,  1906,  p.  343. 


110  OPERATIVE  MIDWIFERY 

With  hydramnios,  another  condition  which  often  causes  the  preg- 
nant woman  great  discomfort,  one  has  less  hesitation  in  bringing  on 
Labour,  for  the  child  or  children  (plural  pregnancy  is  common)  are 
often  very  weakly.  It  must  not  he  forgotten,  however,  that  when 
hydramnios  develops  in  the  later  weeks  of  pregnancy,  the  children 
may  he  horn  quite  healthy  and  strong.  Early  and  acute  hydramnios 
usually  calls  for  interference,  and  at  all  times  the  pregnancy  must  be 
interrupted  if  the  condition  is  causing  severe  general  disturbance  and 
impairment  of  the  respiratory,  circulatory,  and  digestive  functions  of 
the  mother. 

As  regards  affections  of  the  kidneys  in  pregnancy,  one  meets  with 
them  in  several  different  forms.  Chronic  cirrhosis  has  been  already 
referred  to.  What,  to  all  intents  and  purposes,  is  an  acute  nephritis 
may  attack  the  pregnant  woman.  The  features  of  it  are  its  sudden 
onset  and  the  presence  of  large  quantities  of  albumin  and  blood  in 
the  urine.  Then  there  are  the  cases  of  '  pregnancy  kidney,'  with 
often  only  a  slight  amount  of  albumin,  but  an  amount  which  is  very 
variable,  and  often  suddenly  increases.  In  many  of  these  cases  the 
albumin  disappears  soon  after  delivery  ;  sometimes  in  two  or  three 
days  it  is  entirely  gone.  In  a  certain  number,  however,  it  continues 
for  long  after  parturition,  sometimes  for  weeks  and  months.  Indeed, 
I  know  of  two  cases  in  which  it  has  never  disappeared,  and  the  women 
are  now  the  subjects  of  chronic  nephritis. 

With  each  of  the  varieties  mentioned  eclampsia  may  develop,  and 
with  the  two  first  it  may  develop  very  suddenly.  If,  however,  the 
patients  are  under  observation,  and  are  suitably  treated,  it  can 
generally  be  wardeo  off.  Not  infrequently  the  foetus  dies,  and  labour 
supervenes.  "When  eclampsia  does  threaten,  as  is  evidenced  by 
severe  headache,  epigastric  pain,  and  amaurosis,  and  the  ordinary 
means  to  avert  it  do  not  avail,  induction  of  labour  must  be  had 
recourse  to. 

In  connexion  with  the  subject  of  induction  of  labour  and  albu- 
minuria, to  my  mind  the  most  difficult  cases  to  come  to  a  decision 
upon  are  those  in  which,  in  spite  of  treatment,  albumin  continues  in 
considerable  amount.  These  are  the  cases  when  it  often  continues  for 
long  after  labour,  and  sometimes  even  becomes  chronic.  In  such  cases 
one  has  to  consider  induction,  not  so  much  because  of  the  danger  of 
eclampsia,  which,  although  sometimes  occurring,  can  generally  be 
averted  by  suitable  treatment,  as  the  danger  of  a  chronic  cirrhosis  of 
the  kidney  being  established. 

I  cannot  express  a  decided  opinion  upon  these  cases,  but  I  have 
once  or  twice  seen  such  slow  recovery — months  of  albuminuria  after 
delivery,  and  in  two  cases  chronic  cirrhosis  established — that  a  few 


INDUCTION  OF  PREMATURE  LABOUR  441 

more  similar  experiences  would  decide  me  in  favour  of  induction  of 
labour  whenever  the  child  was  viable.  The  difficulty,  of  course,  in 
such  cases  is  that  one  does  not  know  beforehand  whether  or  not  the 
albumin  will  be  slow  in  disappearing.  Personally,  I  have  always 
found  it  slow  in  going  if  it  continues  in  distinct  amount  for  some  time 
before  labour. 

Another  condition  which  calls  for  induction  of  lahour  or  abortion 
is  icterus,  when  it  becomes  pronounced  and  is  attended  with  progres- 
sive general  disturbance. 

Habitual  Death  of  the  Foetus  in  Later  Weeks  of  Pregnancy — 
Protraction  of  Pregnancy  and  Unusual  Size  of  Foetus. 

In  these  conditions  one  often  obtains  satisfactory  results  from 
the  operation  of  induction  of  labour. 

With  habitual  death  of  the  foetus  in  the  later  weeks  of  pregnancy, 
induction  shortly  before  the  date  at  which  the  foetus  usually  dies  (be 
syphilis  the  cause  or  not),  often  proves  very  satisfactory.  With  our 
present  knowledge  there  is  no  exact  means  of  diagnosing  when  the 
life  of  the  foetus  is  in  danger.  We  trust  to  arriving  at  the  date  from 
previous  experience,  and  we  make  sure  of  not  inducing  after  the  death 
of  the  child  by  auscultating  the  foetal  heart.  In  this  connexion  I 
would  mention  one  case  in  which  the  slow  death  of  the  child  in  utero 
was  observed,  although  I  was  unaware  at  the  time  I  was  doing  so. 
The  mother  had  been  most  unfortunate  in  her  pregnancies,  for  two 
■ended  in  dead-born  children  in  the  later  weeks  of  pregnancy  and  two 
in  abortion.  Syphilis  could  be  entirely  excluded.  During  the  preg- 
nancy under  consideration  I  insisted  upon  almost  complete  rest  in  bed, 
and  administered  chlorate  of  potash.  One  day,  about  four  weeks  from 
term,  on  listening  to  the  foetal  heart,  I  found  that  its  character  had 
quite  altered.  One  sound  had  become  very  much  accentuated,  and, 
indeed,  it  very  closely  resembled  the  accentuation  of  the  second  sound 
which  occurs  in  chronic  Bright's  disease.  I  made  this  out  on  a 
Monday,  and  on  the  Wednesday  and  Friday  it  was  even  more  marked. 
•On  the  following  Monday,  when  I  listened,  no  sounds  could  be  heard, 
the  child  was  dead.  Labour  came  on  about  a  week  later,  when 
a  macerated  child  was  expelled.  This  is  the  only  case  of  the  kind  I 
have  had  an  opportunity  of  observing,  nor  do  I  recollect  of  having 
read  any  similar  observation,  so  that  I  can  offer  no  opinion  as  to 
the  frequency  or  value  of  accentuation  of  one  of  the  foetal  heart 
sounds  as  indicating  embarrassment  of  the  foetal  circulation  in 
pregnancy. 

In  protracted  gestation,  without  doubt,  the  child  frequently  suffers, 


142  OPEEATIVE  Ml  DWIFERI 

and  even  dies.  It  is  desirable  to  induce  labour,  therefore,  if  protrac- 
tion of  pregnancy  has  occurred  in  a  previous  gestation,  or  if  in  any 
protracted  pregnancy  the  child  shows  signs  of  having  its  circulation 
embarrassed. 

Und/ue  size  of  the  child  is  sometimes  an  indication  for  induction  of 
labour.  As  a  rule,  if  there  has  been  a  previous  experience  of  difficulty, 
one  is  perfectly  justified  in  having  recourse  to  such  treatment  at  a 
subsequent  pregnancy,  for  each  individual  bears  a  fairly  constant  type 
of  child,  and  it  is  a  peculiarity  of  some  women  to  have  very  large 
children.  Prochownik  has  claimed  that  he  is  able  to  keep  down  the 
size  of  the  child  by  carefully  dieting  the  mother  in  the  later  weeks  of 
pregnancy.  This  is  questioned  by  later  observers.  As  every  one  is 
aware  this  is  a  very  ancient  idea. 

In  the  cases  where  I  have  had  to  consider  the  advisability  .of 
inducing  labour  because  of  the  large  size  of  the  child,  I  have  always 
tested  the  relative  size  of  the  fcetal  head  and  maternal  pelvis  in  the 
thirty-sixth  or  thirty-seventh  week.  If  at  that  time  I  found  the 
head  too  large  for  the  pelvic  brim,  I  have  induced  labour :  if  not,  I 
have  allowed  the  pregnancy  to  continue  for  another  fortnight  and 
again  examined. 


Induction  of  Labour  in  Contracted  Pelvis. 

As  I  have  already  said,  the  greatest  differences  of  opinion  exist  re- 
garding the  value  of  induction  of  labour  in  contracted  pelvis.  It  may 
seem  strange  that  this  should  be  so,  for  the  results  of  many  thousands 
of  cases  upon  which  to  base  a  judgment  of  the  operation  are  now 
available.  But,  as  in  so  many  other  conditions,  the  difficulty  in 
allocating  the  treatment  its  exact  value  is  rendered  impossible  by  the 
attitude  of  extremists  and  partisans. 

The  advantages  of  induction  of  labour  are  that  it  is  an  operation 
very  easily  performed,  and,  if  carried  out  carefully,  is  associated  with 
a  very  small  maternal  mortality.  Indeed,  theoretically,  the  maternal 
mortality  should  be  nil  :  but,  in  spite  of  all  care,  occasionally  infec- 
tion occurs,  and  now  and  then  a  death  from  septicaemia  follows. 
This,  however,  I  would  place  at  not  higher  than  0'6  per  cent.  Among 
my  twenty-two  cases  in  private  and  hospital  practice  in  the  years 
11)01  to  1!)0(),  inclusive,  there  was  no  death.  The  great  objec- 
tion to  the  operation  is  the  high  fcetal  mortality.  In  my  twenty-two 
cases  I  had  a  fa'tal  mortality,  immediate  and  late,  of  36  per  cent.,  and 
that  in  spite  of  the  fact  that  I  took  every  possible  care  in  selecting 
my  cases.  In  judging  of  the  value  of  induction  of  labour,  one  must 
take  the  late  as  well  as  the  immediate  mortality.     The  terms  explain 


INDUCTION  OF  PREMATURE  LABOUR  443 

themselves.  Immediate  implies  that  the  children  are  born  dead ;  late, 
that  they  die  within  two  or  three  weeks  of  their  birth. 

If  one  only  thinks  of  it,  many  circumstances  favour  a  high  foetal 
mortality.  First  and  foremost  is  the  fact  that  the  child  is  premature, 
and  so  is  more  delicate  and  difficult  to  rear.  Especially  is  this  the 
case  amongst  the  poorer  classes,  who  are  unable  to  give  the  premature 
child  the  necessary  amount  of  care  and  attention  it  requires. 

Then  there  is  the  great  difficulty  in  determining  the  age  of  the 
child  in  utero.  This,  also,  is  especially  seen  in  hospital  patients,  who 
have  only  a  vague  recollection  of  such  dates  as  the  last  menstruation, 
the  onset  of  morning  sickness,  quickening,  etc.,  from  which  one 
estimates  the  age  of  a  pregnancy.  It  is  no  uncommon  occurrence  for 
women  to  come  to  hospital  with  the  statement  that  they  have  reached 
'  full  time,'  and  yet  to  find  that  they  are  only  in  the  eighth  month  ;  or 
to  give  the  story  that  they  are  only  eight  months  pregnant,  and  a  day 
or  two  after  they  are  delivered  of  full-time  children.  In  private 
practice,  however,  this  difficulty  does  not  arise  so  often. 

If  conditions  are  favourable,  and  the  different  parts  of  the  foetus  can 
be  palpated,  one  can  form  a  rough  estimate  of  the  size  of  the  child.  One 
i  may  even  measure  the  length  of  the  foetal  ovoid,  which  works  out  about 
half  the  length  of  the  child,  and  from  that  determine  the  age  of  the 
!  foetus.  But  it  is  a  very  approximate  estimate  that  can  be  made  by 
such  a  rough-and-ready  calculation,  and  it  is  really  of  no  practical 
value. 

It  is  generally  stated  that  twenty-eight  weeks  is  the  viable  age, 
and  it  would  appear  from  recorded  cases  that  children  have  been 
reared  born  at  that  age.  It  has  been  found  by  all,  however,  that 
below  the  age  of  thirty-four  weeks  the  chances  of  the  child  surviving 
are  very  small  indeed  ;  and,  after  all,  it  is  upon  that  that  we  must 
base  our  estimate  of  the  value  of  the  operation.  I  feel  convinced, 
from  my  own  experience  and  from  the  records  of  others,  that  induc- 
tion should  be  performed  not  earlier  than  the  thirty-fifth  or  thirty- 
sixth  week.  The  statistics  of  the  Glasgow  Maternity  Hospital  bear 
this  out.  Until  a  few  years  ago  it  was  the  custom  in  the  hospital 
to  induce  labour  even  earlier  than  the  thirty-fourth  week,  the  date 
which  by  almost  general  consent  is  now  admitted  as  the  earliest 
at  which  the  operation  should  be  performed.  We  have  given  that 
practice  up,  however,  and  personally  I  have  never  intentionally  induced 
labour  before  the  thirty-fifth  week. 

It  will  be  seen  at  once  from  Black's  paper  on  '  Induction  of  Labour ' 
in  the  Glasgow  Maternity  Hospital,  1896  to  1898,1  how  fatal  as  regards 
the  interests  of  the  child  induction  earlier  than  the  thirty -fourth  week 
1  Trans.  Glas.  Obst.  and  Gyn.  Soc,  vol.  ii.,  p.  121. 


441  OPERATIVE  MIDWIFERY 

is.  Taking  Black's  cases,  where  the  pelvis  was  3  J  to  3  inches,  the 
foetal  mortality  when  induction  was  performed  before  the  thirty-fourth 
week  was  80  per  cent.,  and  after  40  per  cent. 

Here  arises  a  point  of  practical  importance.  In  looking  over  the 
older  reports  in  the  ward  journals  of  the  hospital,  it  is  often  not  a 
little  difficult  to  tell  what  the  exact  age  of  the  fo-tus  was  when  labour 
was  induced,  for  the  operation  is  generally  stated  as  having  been 
performed  at  such  and  such  a  month.  It  is  most  undesirable  to 
speak  of  months  in  pregnancy;  one  must  reckon  by  weeks — for  when 
months  are  mentioned,  who  knows  whether  lunar  or  calendar  months 
are  meant,  or  whether  the  beginning  or  the  end  of  the  month  is 
referred  to  ? 

As  influencing  the  results  of  induction  of  premature  labour  for 
pelvic  deformity,  we  must  now  consider  another  all-important  factor 
— the  pelvic  capacity.  It  is  perfectly  evident  that  as  one  passes  from 
the  slighter  to  the  more  pronounced  degrees  of  pelvic  deformity  the 
foetal  mortality  must  gradually  increase,  until  it  becomes  so  high  that 
the  operation  is  futile,  and  should  not  be  considered. 

It  is  seldom  necessary  to  induce  labour  when  the  pelvic  deformity 
is  very  slight,  say  a  conjugata  vera  of  3f  inches  (8'3  centimetres), 
unless  the  foetal  head  is  of  unusual  size.  That  is  determined  by 
estimating  the  relative  size  of  foetal  head  and  maternal  pelvis. 

As  regards  the  lowermost  limit  let  us  see  how  matters  stand. 
Bar1  states  that  in  fourteen  cases  where  the  conjugate  was  from 
7  centimetres  or  under,  and  labour  was  induced,  the  fo-tal  mortality 
was  85*7  per  cent.  Black,  in  his  record  of  fifty-two  cases,  mentions 
fourteen  in  which  the  conjugate  was  from  2h  to  2|  inches  (6*2  to  7*2 
centimetres).  In  these  cases  the  early  and  late  mortality  amounted 
to  78*5  per  cent.,  a  mortality  very  comparable  to  that  given  by  Bar. 
These  figures  are  sufficient  to  prove  how  hopeless  the  operation  is 
when  the  pelvis  is  below  3  inches  (7*5  centimetres).  So  convinced 
of  this  have  obstetricians  become  that,  without  exception,  all  are 
agreed  that  induction  should  not  be  performed  in  pelves  of  such  small 
dimensions.  Induction  of  labour  should  not  be  considered,  therefore, 
if  a  patient  has  a  pelvis  with  a  conjugata  vera  of  less  than  3  inches 
(7*5  centimetres),  except  in  the  extremely  rare  cases  where,  after 
carefully  estimating  the  size  of  the  head  and  the  pelvis,  the  head  is 
found  so  unusually  small  that  it  will  pass  through  the  pelvis  without 
much  difficulty  at  the  thirty-sixth  week. 

Let  us  now  turn  to  cases  in  which  the  pelvis  is  a  little  larger, 
and  where  there  is  some  prospect  of  the  operation  being  successful. 
Here  is  a  table  of  my  twenty-two  cases,  showing  the  immediate  and 

1  '  Le<;ons  cle  Pathologie  Obstetricale,'  1900,  p.  147. 


INDUCTION  OF  PREMATURE  LABOUR  445 

late  fcetal  mortality  in  the  different  'degrees  of  pelvic  deformity  :  the 
terms  early  and  late  have  been  already  explained  (p.  443). 

Table  of  Author's  Cases  of  Induction  of  Labour  in  Contracted  Pelvis, 

1901-1906. 

Conjugata  Vera,  3"  (7-5  era.).  Conjugate  Vera,  Z\"  (S-l  cm.).  Conjugate  Vera,  3J"  (S7  cm.). 


Total  cases,  9. 
Fcetal  mortality  (early 
and  late),  44  per  cent. 


Total  cases,  9.  Total  cases,  4. 

Fcetal  mortality   (early        Fcetal  mortality  (early 
and  late),  33  per  cent.  and  late),  25  per  cent. 


My  experience  with  a  pelvis  of  3  to  3 -J-  inches  (7-5  Co  7*8  centi- 
metres) is  a  foetal  mortality  of  44  per  cent.  Bar1  found  in  fourteen 
cases  with  a  conjugate  of  7"1  to  8  centimetres  that  the  mortality, 
(early  and  late)  was  53*3  per  cent.  Pinard,2  for  the  same  deformity 
gives  for  sixteen  cases  an  immediate  and  late  mortality  of  only 
33*3  per  cent.  Kronig,3  for  Zvveifel's  Klinik,  puts  it  at  57'4  per  cent. 
Taking  Leopold's4  two  groups,  which  together  nearly  correspond  to 
those  of  Bar  and  Pinard,  we  find  in  his  twenty-one  cases  an  immediate 
and  late  mortality  of  57  per  cent.  Black's  figures  for  practically  the 
same  measurements  give  61  per  cent. ;  but,  then,  in  two  cases  which 
died  the  labour  was  induced  decidedly  before  the  thirty-fourth  week. 
If  these  two  cases  are  excluded,  so  as  to  bring  the  conditions  as  nearly 
as  possible  comparable  with  the  others,  Black's  results  work  out  in 
eleven  cases  at  54-5  per  cent,  mortality,  a  figure  almost  identical  with 
those  of  Bar,  Leopold,  and  Kronig. 

Every  one,  I  think,  must  admit  that  these  results  are  very  dis- 
appointing. Even  Pinard's  of  33  3  per  cent.,  so  much  better  than  the 
others,  is  a  huge  fcetal  mortality.  So  much  has  this  impressed 
Bar  that  he  states  he  has  now  given  up  inducing  labour  if  the 
pelvis  is  less  than  8  centimetres  (3J  inches).  Kronig  points  out  a 
most  interesting  fact,  that  with  pelves  of  the  deformity  mentioned 
the  foetal  mortality  was  only  63  per  cent,  where  the  labour  was 
allowed  to  go  on  to  term.  Recently  Baisch5  has  come  to  a  similar 
conclusion. 

Taking,  now,  cases  where  the  pelvis  is  slightly  larger,  one  finds, 
where  the  conjugata  vera  is  3|  to  3h  inches  (8'1  to  8'7  centimetres),  a 
distinct  improvement  as  regards  the  foetal  mortality.     My  results  for 

1  Op.  cit.  2  Arm.  de  Gyn.  et  cVObst.,  1902,  Bd.  xxxv. 

"  '  Die  Tnerapie  beirn  engen  Becken,'  Leipzig,  1901. 

4  '  Arbeit  aus  der  Koniglichen  Frauenklinik,'  Dresden,  Bd.  i.,  p.  95. 

5  'Reformen  der  Therapie  des  engen  Becken,'  Leipzig,  1907,  p.  120. 


in;  OPERATIVE  MIDWIFERY 

:;]  inches  (8'1  centimetres)  arc  88  per  cent.,  and  for  3J  inches 
(8*7  centimetres)  25  per  cent.  Bar  found  that,  with  a  conjugata  vera  of 
h-1  to  8*5  centimetres,  the  foetal  mortality  was  31*5  per  cent.  Leopold 
for  the  same  figures  gives  his  as  25  per  cent.  But  even  these  results 
are  not  very  encouraging  ;  indeed,  if  I  compare  them  with  my  results 
from  forceps  (23  per  cent,  and  15  per  cent,  respectively),  it  is  at  once 
evident  that  the  child  has  a  much  better  chance  <>i  surviving  in  this 
particular  degree  of  "pelvic  deformity  it  the  pregnancy  is  left  alone 
ami  labour  allowed  to  terminate  spontaneously,  <</•  if  forceps  are  employed^ 
I  do  not  for  a  moment  doubt  that  if  cases  were  chosen  from  one's 
private  practice  and  where  one  could  be  certain  that  pregnancy  had 
advanced  to  the  thirty-sixth  week,  better  results  would  be  obtained ; 
but  that  in  hospital  practice  they  can  ever  be  made  as  good  or  better 
than  the  results  from  forceps,  with,  if  need  be,  symphysiotomy  or 
pubiotomy,  I  very  much  doubt. 

To  consider  the  results  of  induction  when  the  conjugata  vera  is 
more  than  3|  inches  (8*7  centimetres)  is  hardly  necessary,  for  although 
with  such  treatment  the  foetal  mortality  will  be  very  low,  so  also  will 
it  be  with  forceps  ;  and  not  only  that,  but  in  a  very  large  proportion 
of  cases  forceps  will  not  be  necessary,  for  the  labour  will  actually 
terminate  spontaneously. 

The  conclusion  I  have  come  to,  therefore,  from  my  own  experience 
and  from  the  records  of  others,  is  that  induction  of  labour  is  of  little 
value,  if  the  conjugata  vera  is  below  3}  inches  and  above  Sh  inches 
(8*7  centimetres). 

I  have  found  the  following  course  the  best  to  pursue  in  decidinj;  as 
to  whether  or  not  induction  of  labour  is  suited  for  a  particular  case  of 
pelvic  deformity:  During  the  pregnancy,  the  general  capacity  of  the 
pelvis  is  estimated,  and  the  conjugata  vera  is  very  carefully  measured. 
If  it  is  below  3  inches  (7*5  centimetres),  all  idea  of  induction  is 
abandoned.  Should,  however,  the  pelvis  be  3  inches  (7'5  centimetres) 
or  more,  the  patient  is  told  to  return  at  the  beginning  of  the 
thirty-fifth  week,  when  she  is  prepared  for  operation  (the  pubes 
shaved,  the  parts  about  the  vulva  thoroughly  cleansed,  and  the  vagina 
carefully  washed).  She  is  again  examined  under  chloroform,  and 
the  relative  size  of  the  fcetal  head  and  maternal  pelvis  estimated. 
With  few  exceptions,  at  this  time,  cases  in  which  the  conjugata  vera  is 
•less  than  3j  inches  (8*1  centimetres)  can  be  put  aside  as  unsuitable. 
Wlien  the  conjugata  vera  is  3]  to  3!  inches  (8*1  to  8"7  centimetres), 
however,  the  greatest  possible  care  is  taken  in  estimating  the  relative 
size  of  foetal  head  and  maternal  pelvis.  Some  cases  are  dismissed  as 
unsuitable  because  the  head  is  too  large  for  the  pelvis  ;  "titers  are 
■allowed  to  go  on   to  term  because   the  head  can  be  easily  /aisled  into 


INDUCTION  OF  PKEMATUEE  LABOUR  447 

the  pelvis  ;  and  others  are  deemed  statable  for  induction  because  the  head, 
although  a  little  larger  titan,  the  brim,  is  considered  not  too  large  to 
jyass  through.  If  these  rules  are  followed,  the  best  results  will  be 
obtained  from  induction  of  labour,  and,  if  the  results  are  not  as  satis- 
factory as  one  would  desire,  there  will  at  least  be  the  satisfaction  that 
the  methods  of  arriving  at  a  decision  regarding  the  operation  have 
been  thoroughly  sound  and  scientific. 

Another  circumstance  influences  very  decidedly  the  footal  mortality 
in  induction  of  premature  labour — viz.,  whether  or  not  any  operative 
interference  is  had  recourse  to  in  the  delivery.  The  premature  foetus 
bears  operative  interference  badly.  Every  writer  emphasizes  this, 
and  all  are  agreed  regarding  the  huge  foetal  mortality  when  there 
is  any  difficulty  with  the  after-coming  head.  Take  the  results 
in  Leopold's  Clinic  :  with  primary  breech  presentations  the  mortality 
was  60  per  cent.,  with  head  presentations  it  was  15  per  cent.  From 
Black's  fifty  cases  the  mortality  was  25,  41,  and  48  per  cent.,  according 
as  the  labour  terminated — spontaneously,  by  forceps,  or  by  version. 

There  is  yet  another  factor  which  must  be  mentioned  as  influencing 
the  foetal  mortality,  and  it  is  the  last  which  I  shall  refer  to — the 
method  employed  for  bringing  on  the  labour. 

Most  operators  recommend  that  great  care  should  be  taken  to 
prevent  rupture  of  the  membranes,  and  that  the  oldest  method,  that 
of  puncturing  the  membranes,  is  bad ;  yet  quite  recently  Herff1  wrote 
a  monograph  on  the  advantage  of  this  method,  and  gave  his  primary 
and  late  mortality  in  fifty  cases  as  12  and  18  per  cent,  respectively. 
Kroemer,2  on  the  other  hand,  for  the  G-iessen  Clinic,  where  they 
employ  the  metreurynter,  gives  for  ninety-two  cases  an  early  and 
late  mortality  of  18  and  29  per  cent.  Lastly,  Heller,3  for  the 
Leopold  Clinic,  in  thirty  cases  where  accouchement  force  with  Bossi's 
dilator  was  employed,  gives  the  early  and  late  mortality  as  16  and 
30  per  cent,  respectively.  As  far  as  statistics  go,  therefore,  it  would 
appear  as  if  one  method  is  as  good  as  another.  In  my  cases  there 
has  been  a  higher  foetal  mortality  with  the  metreurynter  than  with 
the  bougie,  and  I  am  inclined  to  think  that  in  a  long  series  of  cases 
the  bougie  would  give  the  best  results. 

In  conclusion,  I  must  confess  that  up  to  the  present  induction  of 
labour  in  contracted  pelvis  has  disappointed  me,  except  in  private 
practice,  and  that  in  spite  of  the  fact  that  I  have  chosen  my  cases 
with  the  greatest  care.  Nor  do  I  stand  alone  in  holding  pessimistic 
views  of   the   operation.     Pinard,  Zweifel,    and  Whitridge  Williams 

1  Volkmann's  Samml.  Klin.  Vortrdge,  No.  386. 

2  Monat.  f.  Geb.  u.  Gyn.,  1904,  vol.  xx.,  p.  901. 

3  Archiv  f.  Gyn.,  1904,  Bd.  lxxiii.,  p.  554. 


448  operative  midw  ifi:i;y 

condemn  it,  and  many  other  operators,  including  liar,  Schauta, 
Leopold,  and  Olshauscn,  although  believing  it  suitable  for  certain 
cases  very  carefully  chosen,  do  not  speak  of  it  very  enthusiastically. 
Williamson,1  in  a  most  excellent  review  of  the  subject,  speaks  of  it 
more  hopefully,  and  recently  when  the  subject  was  very  fully  discussed 
by  some  of  the  leading  British  obstetricians  at  the  meeting  of  the  Royal 
Society  of  Medicine,-  and  again  at  the  Earveriao  Society,8  surprisingly 
good  results  were  recorded.  For  example,  Blackner  recorded  a  foetal 
mortality  in  81  cases  of  25  per  cent,  and  Eden  for  101  cases  in  (^ueen 
(  harlotte's  Hospital  a  mortality  of  only  18  per  cent. 

Methods  for  Induction  of  Premature  Labour. 

It  may  be  of  interest  if  I  enumerate,  as  nearly  as  possible  in  their 
chronological  order,  the  various  methods  which  have  been  employed 
for  bringing  on  premature  labour.  The  dates  are,  for  the  most  part, 
those  given  by  Fasbender.4 

1.  Ecbolics,  used  from  earliest  times  to  procure  abortion. 

2.  Rupture  of  the  membranes  (referred  to  sometimes  as  the 
English  method,  1756  ;  sometimes  as  Scheel's  method,  1799). 

3.  Separation  of  membranes  (Hamilton,  1810). 

4.  Massage  of  breasts  (Friedrich,  1839).  The  sympathy  between 
breasts  and  uterus  was  known  from  earliest  times.  For  inducing 
abortion,  therefore,  the  method  is  of  great  antiquity. 

5.  Massage  of  uterus  (Ulsamer  and  d'Outrepont,  1820). 

6.  Sponge  tents  in  cervix  (Briinninghausen,  1820).  .Etius 
in  the  sixth  century  employed  this  method  for  removing  the  dead 
foetus. 

7.  Injection  of  fluid  under  membranes  (Cohen's  method,  184G). 

8.  Instrumental  dilatation  of  cervix  from  earliest  times. 

9.  Vaginal  tampon  (Scholler,  1842). 

10.  Electricity  (Herden,  1802;  Schreiber,  1843;  Radford,  of 
Manchester,  1793). 

11.  Introduction  of  catheter.  Generally  known  as  Krause's 
method  (1855),  but  described  by  Hamilton  some  years  earlier,  and  by 
Mampe  in  1836). 

12.  Hot  vaginal  douche  (Kiwisch,  1846)  ;  Scanzoni,  hot  carbolic 
douche,  1856. 

13.  Rubber  bag  in  cervix  (Barnes,  1861  i. 

1  Journ.  Obst.  and  Gun.  Brit.  Empire,  March.  1906. 

2  Journ.  Obst.  and  Gyn.  Brit.  Empire,  April,  1910. 

3  Journ.  Obst.  and  Gyn.  Brit. Empire,  May,  1910. 
1  '  Geschichte  der  Geburtshiilfe,'  1906. 


INDUCTION  OF  PREMATURE  LABOUR  440 

14.  Metreurynter  (Tarnier,  1862,  Braun,  Miiller,  Charapetier  de 
Ribes,  etc.). 

15.  Laminaria  tents  (Wilson,  1865). 

16.  Tampon  in  cervix  (Kehrer,  1888). 

17.  Injection  of  glycerine  under  membranes  (Pelzer,  1891). 
Although  there  are  all  the  above-mentioned  devices  for  bringing 

on  premature  labour,  only  a  very  few  are  actually  employed.  Those 
which  require  mention  are  :  The  introduction  of  bougies ;  the  in- 
jection of  fluids  underneath  the  membranes ;  metreurynters ;  and 
dilatation  of  the  cervix. 

It  will  be  observed  that  I  have  not  included  the  oldest  method — 
rupture  of  the  membranes — although  Herff1  and  Reynier,2  in  recent 
monographs  on  the  subject,  have  strongly  advocated  it.  Almost 
every  one  else  is  agreed  that  it  is  undesirable  to  rupture  the  mem- 
branes before  dilatation  of  the  cervix  has  been  effected.  Herff 
claims  that  by  this  method  there  is  less  chance  of  sepsis,  a  greater 
certainty  of  a  favourable  presentation,  and  less  liability  of  prolapse  of 
the  cord.  His  total  foetal  mortality  in  fifty  cases,  immediate  and  late, 
is  only  18  per  cent.  I  am  inclined  to  think,  however,  that  his  results 
are  as  much  due  to  the  care  with  which  the  cases  were  selected  and 
managed  as  to  the  method  employed. 

Insertion  of  a  Bougie  between  the  Membranes  and  Uterine 
Wall — Krause's  Method. — Although  this  method  is  generally  known 
as  Krause's  method,  it  was  really  suggested  by  Hamilton  years  before 
for  cases  in  which  simple  separation  of  the  membranes  was  not 
sufficient.  It  is  the  method  which  is  most  generally  favoured,  and 
the  one  which,  with  few  exceptions,  has  been  employed  in  the 
Glasgow  Maternity  Hospital.  Before  considering  the  advantages  and 
disadvantages  of  the  method,  let  me  describe  how  it  is  carried 
out.  The  patient,  after  being  carefully  prepared  for  operation,  is 
anaesthetized.  The  bougie  can,  of  course,  be  passed  into  the  uterus 
without  anaesthetizing  the  patient,  but  it  is  much  less  convenient,  and 
there  is  greater  danger  of  rupturing  the  membranes.  Besides,  the 
risks  of  sepsis  are  increased,  for,  with  the  patient  under  an  anaesthetic, 
the  vulva  and  vagina  can  be  much  more  carefully  cleansed  and  the 
bougie  more  easily  inserted.  The  bougie  should  be  a  gum-elastic  one, 
and  of  large  size,  and  should  be  sterilized  either  by  soaking  in  per- 
chloride  of  mercury — 1  in  1,000 — for  twenty-four  hours,  or  by  ^boiling- 
The  bougie  should  be  placed  ready  for  use  in  a  tepid  solution  of  weak 
lysol,  by  which  means  it  will  be  pliant  without  being  too  soft.  If 
it  is  too  rigid  the  membranes  are  apt  to  be  ruptured,  and  if  too  soft  it 
curls  up  and  cannot  be  easily  inserted. 

1  Op.  cit.  2  Beitrage  Geb.  u.  Gyn.,  1905   Bd.  ix. 

29 


45c  i        oi'i;i;ati\  i:  midwjit.hy 

The  cervix  should  he  seized  by  a  pair  of  valsellum  forceps,  l»ut  no 
great  traction  must  be  made  upon  it,  as  otherwise  tearing  will  result. 
If  a  linger  cannot  he  passed  through  tlie  cervix,  then  Hegars  dilators 
should  he  employed  to  stretch  the  canal  a  little.  As  they  are  fairly 
blunt-pointed,  they  do  not  rupture  the  memhranes.  .Before  passing 
in  the  bougie,  the  membranes  should  he  separated  from  the  lower 
segment  by  sweeping  a  finger  round.  This  favours  the  onset  of 
labour,  hut,  more  important,  it  lessens  the  risk  of  rupture  of  the 
membranes,  for  the  bougie  passed  in  worms  its  way  round  the  mem- 
branes, whereas  if  the  membranes  are  still  adherent  when  it  is 
inserted,  it  is  very  apt  to  be  pushed  through  them.  I  usually  p 
the  bougie  up  the  posterior  wall  of  the  uterus,  as  it  is  easier  than 
passing  it  up  along  the  anterior  wall.  Occasionally  I  have  found  the 
progress  of  the  bougie  arrested  by  what  was  evidently  the  placenta, 
but  the  partially  withdrawing  it  and  pushing  it  in  another  direction 
got  over  the  difficult}7.  Only  once  have  I  seen  severe  haemorrhage. 
This  was  due,  apparently,  to  separation  of  the  placenta  or,  possibly, 
rupture  of  the  circular  sinus.  The  bleeding  was  so  profuse  that  I  was 
compelled  to  plug  the  cervix  and  vagina. 

The  bougie  should  be  pushed  right  home,  and  sterilized  gauze 
packed  into  the  vagina  over  a  vaginal  retractor  or  speculum. 

I  leave  the  bougie  in  the  uterus  until  labour  is  decidedly  in 
progress.  If  labour  has  not  commenced  after  forty-eight  hours,  I 
again  put  the  patient  under  an  anaesthetic,  remove  the  bougie,  forcibly 
dilate  the  cervix — which  is  then  usually  much  softer  and  more  easily 
stretched — and  insert  a  hydrostatic  dilator.  It  is  quite  safe  to  leave 
the  bougie  for  an  indefinite  period :  consequently,  many  operators 
leave  the  bougie  undisturbed  and  give  hot  vaginal  douches  twice  daily 
until  labour  starts. 

The  advantages  of  Krause's  method  of  inducing  premature  labour 
just  described  are  obvious.  In  theoiy  it  is  the  best  of  all  methods,  for 
it  is  the  simplest  reliable  way  of  bringing  about  uterine  contractions 
and  a  truly  normal  labour.  But,  unfortunately,  it  has  one  great 
drawback,  and  that  is  the  uncertainty  as  to  when  labour  will  actually 
follow  the  introduction  of  the  bougie.  On  several  occasions  I  have 
seen  two  or  three  days  elapse.  Indeed,  I  had  a  case  in  which  labour 
did  not  come  on  for  five  days.  For  many  reasons  that  is  inadvisable  ; 
it  keeps  the  patient  and  her  relatives,  not  to  mention  the  accoucheur, 
on  tenter-hooks.  Besides,  valuable  time  is  lost,  and,  except  in  cases 
of  contracted  pelvis,  the  condition  of  the  mother  wdiich  necessitates 
the  induction  of  labour  may  in  the  meantime  become  much  more 
grave.  For  these  reasons,  therefore,  in  all  cases  before  introducing 
the  bougie,  I  dilate  the  cervix  and  separate  the  membranes :  and  if 


INDUCTION  OF  PREMATURE  LABOUR  451 

labour  does  not  start  in  forty-eight  hours,  I  remove  the  bougie  and 
introduce  a  metreurynter. 

Induction  of  Labour  by  Means  of  the  Metreurynter  of  Tarnier, 
Muller,  and  Champetier  de  Ribes. — The  metreurynter  in  most  general 
use  is  that  of  Champetier  de  Ribes.  Before  it  can  be  inserted  the 
cervix  must  be  dilated  to  the  extent  of  allowing  at  least  two  fingers 
to  pass,  and  that  is  not  always  easy  of  accomplishment,  especially  in 
the  case  of  a  primipara.  To  get  over  this  difficulty  expanding  tents, 
kept  in  place  by  firm  vaginal  packing  for  twelve  hours,  may  be 
employed ;  but  this  complicates  the  operation,  and  necessitates  two 
anaesthesias  within  a  very  short  time.  When  at  all  possible,  there- 
fore, it  is  better  to  dilate  the  cervix  and  introduce  the  metreurynter 
at  one  sitting.  Details  regarding  the  operation  are  given  in 
Chapter  XXVIII. 

An  important  question  arises  at  this  point :  Should  the  mem- 
branes be  ruptured  before  the  metreurynter  is  introduced  ?  I 
certainly  think  the  membranes  should  be  ruptured  if  large  bags  are 
employed,  as  with  undilated  membranes,  the  intra-uterine  pressure 
being  greatly  increased,  there  is  a  decided  danger  of  rupture  of  the 
uterus.  This  danger  is  especially  great  in  placenta  praevia.  If,  how- 
ever, only  a  small  bag  is  employed — one,  in  fact,  which  is  used  more 
for  the  mechanical  irritation  it  produces  than  for  the  amount  of  dila- 
tation of  the  cervix  that  results — then  it  is  unnecessary  to  rupture  the 
membranes.  An  excellent  procedure,  when  it  is  thought  inadvisable 
to  rupture  the  membranes,  is  to  partially  fill  the  metreurynter,  and 
then  as  the  cervix  expands  to  gradually  add  some  more  fluid.  The 
collapsed  bag,  having  been  introduced  through  the  cervix,  is  filled 
with  sterilized  water,  the  projecting  portion  of  tubing  is  wrapped  up 
in  gauze,  and  the  patient  put  back  into  bed. 

Unless  there  is  some  great  necessity  for  hastening  the  delivery, 
the  uterine  contractions  are  allowed  to  expel  the  bag ;  no  traction 
is  made  upon  the  tube.  The  time  which  elapses  before  the  bag  is 
expelled  varies  greatly,  twelve  hours  being  the  average  in  my  cases, 
although  in  one  it  was  thirty  hours  before  it  occurred.  The  experience 
of  other  writers  is  very  similar.  Kroemer1  states  that  the  average 
time  before  the  onset  of  labour  in  his  ninety-two  cases  with  the 
bougie  was  twenty-four  to  forty-eight  hours,  and  with  the  metreurynter 
fifteen  hours.  The  early  and  late  foetal  mortality  was  31*2  per  cent. 
Zimmermann2  records  twenty-three  cases  of  induction  with  the  bougie 
in  which  the  time  averaged  eighty  hours,  and  ninety  cases  of  induction 
with  the  metreurynter  in  which  it  averaged  seventeen  hours.     This 

1  Monat.  f.  Qeb.  u.  Gyn.,  1904,  Bd.  xx,  p.  901. 
-  Ibid.,  1902,  Bd.  xvi.,  p.  37. 


452  OPERATIVE  MIDWIFERY 

author  does  not  approve  of  rupturing  the  membranes  before  inserting 
the  metreurynter  even  in  cases  of  placenta  previa. 

After  the  expulsion  of  the  metreurynter  the  delivery  of  the  child 
should  be  left  to  Nature.  If  delivery  has  to  be  hastened,  many 
prefer  version,  but  in  the  Glasgow  Maternity  Hospital  we  have  had 
a  higher  fatal  mortality  after  version  than  after  forceps. 

As  far  as  can  be  judged,  in  France  and  Germany  many  obstet- 
ricians at  present  favour  the  metreurynter,  although  they  are  agreed 
that  it  is  a  treatment  hardly  suitable  for  private  practice,  in  which 
induction  by  means  of  the  bougie  or  even  by  rupturing  the  mem- 
branes, according  to  Herff,1  gives  quite  satisfactory  results.  The 
objection  urged  against  it — that  it  displaces  the  presenting  part — is 
largely  theoretical.  The  chief  objection  to  my  mind  is  that  the 
metreurynter  favours  prolapse  of  the  cord.  I  have  found  that  occur 
in  a  considerable  number  of  cases  ;  consequently,  my  results  as  regards 
the  foetus  have  been  worse  with  the  metreurynter  than  with  the 
bougie.  Ahlfeld  is  of  the  same  opinion.  Naturally,  this  danger  can 
be  avoided  by  preserving  the  membranes  intact.  As  regards  the 
mother,  the  morbidity  and  mortality  is  slightly  higher,  and  that  even 
in  the  simplest  of  all  conditions,  contracted  pelvis.  Zimmermann 
for  211  cases  gives  the  mortality  as  2  per  cent,  and  the  morbidity  as 
16  per  cent.  The  most  serious  accident  is  for  the  metreurynter  to 
burst.  In  the  Glasgow  Maternity  Hospital  this  occurred  in  the  hands 
of  my  colleagues  upon  two  occasions.  The  bag  should  therefore  be 
tested  by  filling  it  and  pressing  it  firmly  between  the  hands. 

My  own  feeling  is  that  the  metreurynter  is  suitable  for  induction 
of  labour  in  conditions  in  which  it  is  desirable  that  delivery  should  be 
completed  within  a  short  time,  but  that  the  bougie  is  better  for  con- 
tracted pelvis,  when  it  is  of  no  great  consequence  if  the  onset  of 
labour  is  delayed. 

It  is  unnecessary  to  discuss  the  rubber  bags  of  Barnes  introduced 
into  the  cervix.  They  are  not  suitable  for  induction  unless  intro- 
duced into  the  uterus  and  used  as  a  mechanical  stimulant  to  uterine 
activity. 

The  Injection  of  Fluids  underneath  the  Membranes — Cohens 
Method. — This  method  is  very  seldom  employed.  Even  the  more 
recent  modification  of  Pelzer,  the  injection  of  glycerine,  has  been 
entirely  given  up  because  of  the  danger  attendant  upon  its  employ- 
ment. Simpson,2  amongst  others,  has  discussed  the  method  and 
pointed  out  its  dangers.  There  is  really  nothing  to  be  said  in  its 
favour,  for  it  possesses  no  advantages  over  the  two  previous  methods 
already  described. 

*  Op  cit.  2  Edin.  Mai  Journ.,  April,  1893. 


INDUCTION  OF  PREMATURE  LABOUR  453 

The  other  methods,  enumerated  on  pp.  448  and  449,  are  only  of 
historical  interest.  If  anyone  is  interested  in  them,  I  would  commend 
Kleinwachter's  most  excellent  monograph,1  in  which  each  is  fully 
described. 

Nor  need  I  say  anything  on  the  subject  of  forcible  dilatation  of 
the  cervix  by  means  of  the  hands  or  the  various  metal  dilators.  That 
subject  is  fully  considered  in  connexion  with  accouchement  forced 
Although  Heller2  gives  very  satisfactory  results  from  the  operation  in 
Leopold's  Clinic,  few  are  inclined  to  adopt  it.  Personally,  I  have 
employed  it  only  once  or  twice  when  I  found  that  the  cervix  was 
so  soft  and  dilatable  that  there  was  no  danger  or  difficulty  in  stretch- 
ing it. 

Induction  of  Abortion. 

By  induction  of  abortion  is  meant  the  emptying  of  the  uterus 
before  the  child  is  viable.  It  is  an  operation,  therefore,  which  is  only 
performed  for  some  grave  disease  threatening  the  mother's  life. 

The  indications  for  the  operation  have  been  considered  at  sufficient 
length  in  the  earlier  part  of  this  chapter,  when  induction  of  premature 
labour  was  under  discussion.  Doubtless  some  of  the  rarer  forms  of 
disease  jeopardizing  the  pregnant  woman's  life  have  not  been  men- 
tioned, but  sufficient  has  been  said  to  indicate  when  and  under  what 
circumstances  the  uterus  should  be  emptied. 

The  induction  of  abortion  is  an  operation  which  must  never  be 
lightly  undertaken ;  every  physician  appreciates  this,  and  in  conse- 
quence makes  it  a  rule  to  have  a  consultation  with  a  confrere  before  he 
has  recourse  to  it.  The  disinclination  of  the  accoucheur  to  perform  tha 
operation,  however,  must  not  be  carried  to  an  extreme.  It  has  been  my 
experience  on  many  occasions  to  see  cases  in  consultation  where  the 
medical  practitioner  has  postponed  too  long  the  consideration  of  the 
operation,  and  has  in  consequence  allowed  his  patient  to  become  so 
reduced  in  health  as  to  prevent  her  life  being  saved  even  by  the 
emptying  of  the  uterus.  It  is  evident,  therefore,  that  the  time  for 
interfering  and  inducing  abortion  is  very  difficult  to  decide,  and  can 
only  be  arrived  at  by  carefully  watching  the  patient  from  day  to  day, 
and  estimating  how  far  she  is  resisting  the  disease  and  to  what  extent 
she  is  responding  to  the  prescribed  treatment. 

From  the  middle  of  pregnancy  until  the  twenty-eighth  week — the 
recognized  viable  age — the  operation  should  be  carried  out  in  a  similar 
manner  to  that  recommended  in  induction  of  premature  labour,  for  a 
labour  in  that  period  resembles  very  closely  an  ordinary  parturition. 

1  '  Der  Kunstlichen  Unterbrechung  der  Schwangerschaft,'  3rd  edition,  1902. 

2  Op.  cit. 


-l.-,l  OPERATIVE   MIDWIFERY 

When  one  comes,  however,  to  inducing  abortion  in  the  earlier 
weeks  of  pregnancy,  the  operative  procedures  to  be  adopted  are  some- 
what different.  I  must  admit  that  the  emptying  of  the  uterus  during 
this  period  is  very  often  troublesome,  for  the  uterus  is  often  difficult 
to  stimulate  to  activity.  Indeed,  some  of  the  most  troublesome  cases 
which  1  have  encountered  in  practice  have  been  those  in  which  I  have 
had  to  induce  abortion  about  the  twelfth  or  fifteenth  week. 

There  are,  of  course,  several  recognized  methods  of  emptying  the 
uterus  in  the  early  months  of  pregnancy.  The  most  important  are  : 
(1)  Rupturing  of  the  membranes  ;  (2)  dilating  the  cervical  canal  and 
plugging  the  same  with  gauze:  (8)  dilating  the  canal  gradually  with 
laminaria  tents  or  rapidly  with  metal  dilators. 

While  recognizing  the  value  of  these  methods,  and  while  employing 
them  whenever  possible,  I  have  been  disappointed  more  than  once 
with  the  results  obtained.  I  think  that  once  or  twice  I  failed  to  save 
my  patients  by  these  operative  methods  owing  to  the  delay  they  involved 
or  the  strain  they  threw  upon  the  already  embarrassed  circulation.  The 
choice  of  operation  must  depend  very  largely  upon  the  patient's  con- 
dition. If  her  life  is  in  such  danger  that  the  uterus  must  be  emptied 
within  a  matter  of  a  few  hours,  it  is  profitless  to  attempt  dilatation  of 
the  cervix  by  means  of  laminaria  tents  or  gauze  tampons.  One  has, 
therefore,  in  such  cases  only  the  alternatives  of  rapidly  dilating  or 
incising  the  cervix.  Everyone  must  have  found  that  it  is  often  a 
matter  of  extreme  difficulty  to  dilate  the  cervix  in  the  earlier  weeks  of 
pregnancy  ;  indeed,  in  most  of  the  cases  in  which  I  have  employed 
rapid  dilatation,  or  seen  it  employed,  the  cervix  has  been  torn.  But, 
in  addition,  there  is  another  very  serious  drawback.  Rapid  dilatation 
produces  a  very  considerable  amount  of  shock  unless  the  patient  is 
deeply  anaesthetized,  and,  seeing  that  the  patient  is  already  gravely 
ill,  this  strain  on  the  heart  is  often  just  sufficient  to  remove  her  last 
chance  of  recovery. 

In  such  cases,  therefore,  in  which  the  uterus  must  be  emptied 
immediately  and  with  the  least  amount  of  shock  to  the  patient,  I 
have  recourse  to  incision  of  the  cervix — vaginal  Cesarean  section. 
This  operation  can  always  be  carried  out  with  the  greatest  ease  in  the 
first  twenty  weeks  of  pregnancy.  It  takes  very  little  time,  and,  as 
far  as  I  have  seen,  gives  more  satisfactory  results  than  forcibly  dilating 
the  canal. 

The  technique  of  vaginal  Cesarean  section  is  fully  considered  in 
Chapter  XXVIII.,  so  that  I  need  not  consider  it  here.  The  only 
objection  to  it  is  that  it  requires  a  certain  amount  of  experience,  and 
is  not  an  operation  which  a  general  practitioner  could  undertake 
without  proper  assistance.     As,  however,  in  such  cases  he  will  usually 


INDUCTION  OF  PIIEMATURE  LABOUK  455 

have  a  consultant  associated  with  him,  or,  if  the  patient  is  in  poor 
circumstances,  will  have  her  removed  to  hospital,  I  do  not  consider 
that  the  operation  is  outside  the  bounds  of  practical  obstetrics.  In 
.spite  of  the  fact  that  many  modern  writers  are  opposed  to  this  opera- 
tion in  such  circumstances  as  we  are  considering,  I  am  convinced 
in  my  own  mind  that  it  is  an  operation  of  the  very  greatest  value, 
and,  as  I  have  already  said,  it  is  one  that  I  have  found  give  most 
satisfactory  results. 

Turning  now  to  the  more  usual  cases  where  one  can  take  time  to 
empty  the  uterus,  the  two  methods  —  rupturing  the  membranes  or 
inserting  laminaria  tents  or  gauze  into  the  cervix — can  be  suitably 
employed.  The  simple  method  of  rupturing  the  membranes  is  seldom 
sufficient,  and  there  is  no  doubt  that  the  risk  of  infection  is  very  con- 
siderable when  it  is  employed,  even  if  every  possible  precaution  is 
taken  against  infection. 

The  best  course  to  pursue  when  one  has  the  choice  is  to  insert  into 
the  cervix  the  largest-sized  laminaria  tent,  and  keep  it  in  its  place  with 
a  vaginal  tampon  of  gauze.  It  is  hardly  necessary  to  state  that  this 
must  be  done  with  every  precaution  against  sepsis.  In  twelve  to 
twenty-four  hours  the  gauze  and  tampon  should  be  removed,  when 
the  cervix  will  be  found  dilated  to  some  extent  and  very  generally 
softer.  After  this  the  cervix  should  be  douched  with  hot  antiseptic 
solution,  and  further  dilated  with  the  finger,  or,  better  still,  with 
the  larger  sizes  of  Hegar's  dilator.  The  canal  and  vagina  should 
then  be  firmly  plugged  with  gauze,  which  should  be  left  in  for  another 
twelve  or  eighteen  hours.  On  removal  of  this  gauze  the  uterus 
should  be  emptied. 

It  is  hardly  necessary  to  caution  against  the  employment  of  the 
curette  for  emptying  the  uterus,  for,  although  this  instrument  is 
suitable  enough  for  the  removal  of  very  early  abortions — say  of  two  or 
three  weeks — it  is  quite  unsuitable  for  the  removal  of  those  which  are 
older  ;  in  the  latter  case  the  finger  and  ovum  forceps  are  a  much 
better  means  for  removing  the  uterine  contents.  This  subject,  how- 
ever, is  more  fully  discussed  in  Chapter  XXXI.,  where  abortion  is 
considered. 


CHAPTER  XXVIII 

ACCOUCHEMENT  FORCE,  INCLUDING  VAGINAL  CESAREAN 

SECTION 

The  operation  of  accouchement  force,  as  we  know  it,  was  an  outcome 
of  the  great  revival  in  midwifery  initiated  by  Ambrose  Pare,  and  the 
term  was  introduced  by  his  pupil  Guillemeau.  It  is,  however,  of 
much  more  ancient  date,  for  references  to  it  may  be  found  in  the 
writings  of  Celsus  and  Galen. 

At  different  epochs  since  Guillemeau's  time  the  operation  has 
come  into  prominence,  as,  for  example,  when  Levret,  in  France,  and 
Osiander,  in  Germany,  reintroduced  pronged  instruments  for  stretch- 
ing the  cervix,  and,  later,  when  Wilson  invented  expanding  tents,  and 
Barnes  and  Tarnier  devised  rubber  bags.  The  most  recent  revival 
occurred  only  a  few  years  ago.  In  great  part  it  was  the  result  of  the 
extension  of  surgical  asepsis  to  obstetric  practice,  although  I  believe 
the  real  cause  was  the  reintroduction  of  expanding  dilators  by  Bossi 
and  others,  and  the  extensive  incisions  of  the  cervix  devised  by  the 
late  Acconci  and  Diihrssen. 

Indications  for  Accouchement  Force. 

It  is  quite  impossible  to  lay  down  hard-and-fast  general  rules 
regarding  the  employment  of  accouchement  force.  Broadly  speaking, 
it  is  indicated  when,  the  cervix  being  still  undilated,  the  life  of  the 
mother  or  child  demand  the  immediate  emptying  of  the  uterus. 

The  favour  in  which  the  operation  is  regarded  varies  greatly,  for, 
while  some  operators  have  recourse  to  it  only  on  very  rare  occasions, 
others  employ  it  freely.  What  makes  it  especially  difficult  to  give  a 
general  idea  of  its  place  is  the  fact  that  many  who  condemn  the  treat- 
ment in  certain  conditions  employ  it  in  others. 

Personally,  I  have  made  use  of  the  operation  for  a  great  variety 
of  conditions,  such  as  accidental  haemorrhage,  placenta  previa, 
eclampsia,  hyperemesis,  cardiac  disease,  and  rigidity  of  the  cervix. 

456 


ACCOUCHEMENT  FOBCE  457 

Regarding  concealed  accidental  lusmorrhage,  as  I  shall  explain  in 
speaking  of  that  complication,  my  results  have  been  most  unsatis- 
factory. This  was  also  the  experience  of  those  who  spoke  on  the 
subject  at  the  meeting  of  the  British  Medical  Association  at  Oxford.1 
In  placenta  pnevia,  although  the  results  have  not  been  so  unsatisfac- 
tory, on  two  occasions  in  the  Glasgow  Maternity  Hospital  very  severe 
rupture  of  the  lower  uterine  segment  occurred.  My  feeling,  then,  is 
that  accouchement  force  is  not  a  suitable  treatment  for  either  of  these 
conditions. 

With  eclampsia  it  is  quite  different.  If  saline  transfusion  and 
morphia  or  chloral  do  not  control  the  seizures,  there  is  no  alternative 
but  to  empty  the  uterus.  When  this  becomes  necessary,  and  the 
cervix  is  already  slightly  dilated  or  very  soft,  forcible  dilatation  with 
the  hands  or  metal  dilators  gives  most  satisfactory  results  ;  but  when 
the  os  is  quite  closed,  the  cervix  not  taken  up,  and  especially  when 
pregnancy  is  several  weeks  short  of  term,  there  are  considerable  risks 
in  employing  expanding  metal  dilators,  on  account  of  the  danger  of 
lacerating  the  cervix.  In  such  cases  the  classical,  and  some  claim 
the  vaginal,  Cesarean  section  have  a  place. 

The  same  treatment  is  indicated  in  those  rare  cases  of  hyper- 
emesis  gravidarum,  heart  disease,  etc.,  which  do  not  respond  to 
medicinal  treatment,  and  where  the  slow  methods  of  inducing  labour 
cannot  be  adopted  because  of  the  patient's  critical  condition. 

As  regards  the  operation  employed  in  the  interests  of  the  child, 
one  should  remember  that  while  the  life  of  the  child  must  on  every 
possible  occasion  have  the  greatest  consideration,  the  child,  after  all, 
comes  second  to  the  mother.  Frequently  the  two  lives  are  directly 
opposed  to  one  another,  for  the  more  one  considers  the  child,  and 
directs  one's  treatment  to  preserving  its  life,  the  greater  will  the 
mother's  life  be  endangered.  This,  naturally,  makes  it  very  difficult 
to  decide  upon  the  course  to  follow.  In  this  connexion,  however,  the 
important  factor,  which  finally  must  determine  the  treatment  to  be 
followed,  is  the  '  prospective  life  '  of  the  child.  In  many  cases  in  which 
accouchement  force  is  indicated,  the  child,  although  alive,  is  not  a 
'good  life.'  It  is  not  only  premature,  but  it  is  probably  the  subject 
of  disease.  In  addition,  it  is  hopelessly  handicapped  by  the  operative 
interference  necessary  for  its  delivery.  Consequently,  the  operation  oj 
accouchement  force  should  seldom  he  performed  in  the  interests  oj  the 
child. 

Before  going  farther,  the  exact  meaning  of  the  term  '  accouche- 
ment force  '  must  be  agreed  upon,  for  it  has  come  to  be  loosely  applied 

1  Brit.  Med.  Jo  urn.,  1904,  vol.  ii. 


458 


OPERATIVE  MIDWIFER1 


to  any  rapid  extraction  of  the  child.  The  two  essential  features  of 
accouchement  force  are  rapid  and  forcible  enlargement  of  the  cervical 
canal  and  immediate  extraction  of  the  child. 

Two  methods  of  enlarging  the  cervical  canal  are  open  to  the 
operator — dilatation  and  incision — while  as  regards  extraction,  it 
may  be  completed  by  forceps  or  version. 

Methods  of  Dilating-  the  Cervix. 

Dilatation,  as  a  step  in  the  operation  of  accouchement  force,  may 
be  carried  out  with  the  hands,  tents,  rubber  bags,  or  expanding  m<  I  J 
dilators.      Strictly  speaking,  only  rapid  dilatation   with    the    fin. 


FlG.  201.—  Manual  Dilatation  of  the  Os.     (After  Edgar.) 


or  with  metal  dilators  can  be  termed  accouchement  force  ;  still,  it  is 
found  convenient  to  include  here  tents  and  metreurynters.  "We  must 
consider  each  of  these  separately,  in  order  to  compare  the  advantages 
and  disadvantages  of  each. 

Before  employing  any  of  these  methods  for  dilating  the  cervix,  let 
me  emphasize  the  extreme  importance  of  taking  every  precaution 
against  sepsis.  In  this  operation  the  risks  of  infection  are  very  great. 
The  hand  is  frequently  introduced  into  the  vagina,  and,  as  the  opera- 
tion is  a  tedious  one,  the  tendency  is  for  the  operator  to  be  less 
careful     in     the    later     stages.       An    additional    precaution    which 


ACCOUCHEMENT  FORCE 


l.v.i 


must  be  taken  in  dilating  the  cervix  is  the  employment  of  deep 
anaesthesia. 

Manual  Dilatation. — -The  obvious  advantages  of  manual  dilata- 
tion, naturally  the  oldest  of  all  methods,  are  that  the  operator 
requires  no  instruments  and  that  he  appreciates  exactly  what  he  is 
doing.  The  disadvantages  are  that  the  operation  takes  time,  is 
usually  impossible  if  the  cervix  is  undilated  and  rigid,  and  is  often 
very  fatiguing. 

Before  dilatation  proper  can  be  commenced,  the  os  uteri  must 
admit  at  least  a  finger.  If  that  is  not  possible,  the  graduated  dilators 
of  Hegar  should  be  employed. 

The  hand,  thoroughly  cleansed  and  encased  in  a  rubber  (/love,  is 
passed  into  the  vagina.  The  forefinger  is  then  introduced  into  the 
cervix,  and  gradually  pushed  farther  and  farther  in.     In  doing  this, 


Fig.  202. — Bimanual  Dilatation  of  the  Os. 


it  is  often  better  to  push  the  uterus  down  upon  the  finger,  with  the 
hand  applied  externally  over  the  fundus,  than  simply  to  try  and 
push  the  finger  up  into  the  uterus.  One  finger  having  been  well 
introduced,  should  be  withdrawn,  and  the  tip  of  a  second  inserted 
with  the  first,  or,  as  Harris  indicates,  the  thumb  may  be  employed 
instead.  The  rest  of  the  operation  may  be  carried  out  by  getting 
more  and  more  of  the  hand  through  (Fig.  "201),  or  by  employing  the 
fingers  of  the  two  hands — Bonnaire's  method  (Fig.  202). 

Could  one  always  dilate  the  cervix  quickly  enough  by  this  method, 
it  would,  without  doubt,  be  the  best,  for  there  is  less  chance  of  tearing 
if  one  moves  the  dilating  fingers  about,  stretching  sometimes  antero- 
posteriorly  and  sometimes  laterally.  Besides,  one  can  tell  better  what 
one  is  doing.  There  is  another  point  also — during  manipulations  the 
cervix  often  becomes  softer. 


460  OPERATIYK   MIDWIFKUY 

Let  me  with  extreme  brevity  give  a  few  illustrative  eases : 

1.  Mrs.   L ,  a  6-para,  twenty-four  weeks  pregnant     Eclampsia      CM 

with  difficulty  admitted  finger,  and    was  extremely  rigid  ;   manual  dilata- 
tion, version  and  extraction.     Duration  of  operation  our  hour  and  a  half. 

2.  A  2-para,  almost  term,  seen  in  consultation  with  Dr.  McM  — . 
Accouchement  force*  on  account  of  dyspnoea.  Manual  dilatation  and 
extraction  with  forceps  took  fifty  minutes.     Child  alive  ;  recovery  complete. 

3.  A    2-para,    twenty-four    weeks    pregnant.      Eclampsia,      Seen    with 

Dr.  L .     Os  admitted  ringer;  dilatation  with  bags  and  fingers,  followed 

by  version  :  os  wiy  rigid.     Operation  took  fully  sixty  minutes.     Recovery 
complete. 

•i.  A  2-para,   about    thirty    weeks  pregnant.     Seen    in  consultation    with 

I>r.    P .     Acute  mania.     Dilatation   with   fingers,   followed   by   version 

and  extraction.     Operation  took  fifty  minutes.     Kecovery  complete. 

These  have  been  casually  chosen  from  amongst  my  cases  of 
manual  dilatation.  In  my  experience  the  shortest  time  taken  to 
dilate  manually,  and  deliver  a  woman  not  in  labour,  has  been  fifteen 
minutes.  This  was  a  case  of  contracted  pelvis,  in  which  I  intended 
to  induce  labour,  but  finding  the  cervix  ver/y  soft,  I  dilated  and 
extracted  the  child.     The  longest  time  was  fully  two  hours. 

Taking  my  cases,  I  would  sa}r  that,  on  an  average,  to  dilate  and 
deliver  a  multipara  not  in  labour,  and  with  the  cervix  not  obliterated, 
an  hour  at  least  is  required  :  and  to  do  the  same  in  a  primipara 
about  an  hour  and  a  half.  I  do  not  include,  of  course,  cases  of 
abortion.  In  such  cases  a  very  considerable  time  is  often  necessary 
to  dilate  the  cervix  manually ;  indeed,  it  is  sometimes  quite  impossible, 
as  I  indicated  in  the  previous  chapter. 

As  I  shall  point  out  later,  when  speaking  of  expanding  metal 
dilators,  dilatation  is  distinctly  more  difficult  and  more  liable  to  be 
complicated  with  laceration  in  the  early  months  of  pregnancy  and  if 
the  cervical  canal  is  unobliterated. 

Dilatation  by  Means  of  Expanding"  Tents. — Dilatation  by  means 
of  expanding  tents  is  a  slow  process,  and  occupies  hours  instead  of 
minutes.  It  is  suitable  for  cases  in  which  there  is  no  hurry  to  empty 
the  uterus.  Laminaria  tents  are  the  only  variety  now  employed 
(Fig.  203).  They  may  be  sterilized  by  dry  heat  or  by  soaking  in 
1  in  1,000  perchloride  of  mercury  and  alcohol  for  forty-eight  hours. 
Hartmann's  tents  in  sealed  glass  tubes  are  the  most  convenient. 

The  method  of  proceeding  when  tents  are  employed  is  as  follows  : 
The  patient,  having  been  anaesthetized,  should  have  a  further  thorough 
disinfection  of  the  external  parts.  The  pubes  should  be  shaved, 
and  the  vagina  washed  out  with  some  soapy  disinfectant,  such  as 
lysol. 


ACCOUCHEMENT  FORCE  1 01 

The  cervix  is  then  seized  with  a  pair  of  vulsellum  forceps,  the 
anterior  and  posterior  vaginal  walls  being  retracted  if  necessary. 
Before  introducing  the  tent  I  have  usually  employed  the  ordinary 
dilators  of  Hegar,  which  must  be  pushed  in  until  one  feels  the  point 
has  passed  beyond  the  internal  os.  No  great  force  should  be  used  ;  if 
that  is  necessary,  one  should  desist. 

The  largest  tent  which  can  be  introduced  is  placed  in  the  cervix. 
In  doing  this  care  must  be  taken  that  the  tent  is  not  pushed  in  too 
far.  This  is  especially  apt  to  occur  when  the  gauze  packing  is  being 
placed  in  the  vagina.  In  order  to  prevent  this  accident  a  loop  of 
strong  silk  should  be  passed  through  the  tent  in  place  of  the  thin 
cord  generally  found  there.  Through  this  loop  is  passed  a  piece  of 
gauze  about  half  a  yard  long,  which,  pushed  into  the  fornices,  anchors 
the  tent  and  prevents  its  displacement.  The  rest  of  the  vagina  is 
packed  firmly  with  gauze.  Sometimes  there  is  not  a  tent  large 
enough  for  the  cervix  ;  in  such  cases  one  can  usually  dilate  with  the 
fingers,  but  if  this  should  be  impossible,  two  or  more  tents  can  be 


Fig.  203. — Laminaria  Tent. 

used  together.  Larger  tents  made  of  several  pieces  of  laminaria 
glued  together  cannot  be  recommended.  Tents  should  be  left  in  for 
twelve  hours  at  least. 

On  their  removal,  the  cervix  should  be  sufficiently  dilated  to 
permit  of  the  fingers  being  introduced,  and  the  further  dilatation  and 
extraction  of  the  child  being  proceeded  with.  If  that  is  still  impossible, 
several  tents  may  be  again  inserted,  and  left  for  another  twelve  hours; 
or  a  metreurynter  may  be  introduced. 

Dilatation  with  Hydrostatic  Dilators — Metreurynter. — At  the 
present  time  '  metreurysis '  is  much  in  favour,  and  many  important 
contributions  to  the  subject  will  be  found  in  recent  Continental  and 
American  literature. 

Rubber  bags,  like  tents,  dilate  the  cervix  very  slowly.  Another 
objection  is  that  they  can  only  he  used  after  the  cervix  has  been 
sufficiently  dilated  to  allow  of  their  introduction.  The  method  is 
consequently  quite  unsuitable  for  cases  in  which  rapid  delivery  is  of 
primary  importance,  and  for  those  cases  of  difficult  dilatation  to 
which  I  have  already  referred. 

Without  doubt,  the  hydrostatic  dilator  of  Champetier  de  Ribes 
or  Muller  is  the  best.     Most  modern  English  writers,  such  as  Herman, 


162 


OPKIIATIYK   MIDWIFERY 


Jellett,  and  Tweedy,  favour  it.  Barnes's  rubber  bage  Pig.  204)  1  have 
always  found  of  little  real  service  when  the  cervix  is  at  all  rigid, 
for  they  simply  balloon  up  inside  the  uterus.  In  the  Maternity  Hos- 
pital, therefore,  we  have  ceased  using  bhem.  A  more  complicated 
metreurynter  is  that  of  Pomeroy  (Fig.  205). 

The  metreurynter  of  ("hanipetier  de  Ribes  is  the  mosl  serviceable 
Pig.  206).  It  is  pear-shaped,  and  made  of  waterproof  silk.  From 
the  apex  a  rubber  tube  passes,  and  through  this  the  bag  is  tilled  with 
sterile  solution.  Before  use  it  should  he  thoroughly  tested  by  firm 
pressure  hetween  the  hands,  as  it  is  liable  to  hurst  if  at  all  old.  Only 
the  other  day  one  burst  in  my  hands  when  I  tested  it.     Bursting  of 


Fig.  204. — Barnes's  Hydrostatic  Dilator. 


the  bag  after  its  introduction  into  the  uterus  has  been  recorded  by 
several  writers. 

The  mode  of  procedure  in  employing  a  Champetier  de  Ribes 
hydrostatic  dilator  is  as  follows  : 

The  patient,  being  anesthetized,  is  brought  to  the  edge  of  the  bed 
and  placed  in  the  lithotomy  position.  The  pubes,  vulva,  and  vagina 
are  then  thoroughly  cleansed.  If  necessary,  the  cervix  is  steadied  by 
vulsellum  forceps.  Having  grasped  the  bag  with  a  long  pair  of  clamp 
forceps,  or  the  special  forceps  for  the  purpose  (Fig.  207),  the  bag  is 
carried  up  into  the  uterus  and  the  forceps  withdrawn.  I  have 
occasionally  found  it  easier  to  insert  the  bag  without  employing  the 
forceps,  simply  using  my  fingers.  The  bag  is  then  slowly  filled  with 
sterilized  solution.  The  tubing  is  then  wrapped  up  in  gauze,  and  the 
patient  is  put  back  to  bed.  Generally  one  allows  the  natural  forces 
to  expel  the  bag ;  but  if  it  is  deemed  necessary  to  hasten  the  dilata- 
tion, traction  may  be  exerted  on  the  tubing  through  a  cord  attached 


ACCOUCHEMENT  FORCE 


If,:', 


to  a  weight  brought  over  the  foot  of  the  bed.  A  very  light  weight  is 
all  that  is  necessary,  say  a  couple  of  pounds.  I  have  already  referred 
(p.  451)  to  the  question  whether  or  not  the  membranes  should  be 
ruptured  before  the  bag  is  inserted. 

When  a  large  Chanipetier  de  Ribes  bag  has  been  expelled,  the 
os  is  sufficiently  dilated  to  allow  the  passage  of  an  average-sized 
child.  If,  however,  the  child  is  larger  than  normal,  the  cervix  will 
require  to  be  more  widely  dilated  with  the  hand.  In  my  experience  it 
is  usually  about  twelve  hours  before  the  bag  is  expelled.  Naturally, 
in  a  multipara,  wdiose  cervix  is  soft  and  dilatable,  it  occurs  sooner 
than  in  a  primipara. 

Dilatation  with  Expansile  Metal  Dilators. — Of  all  methods  of 
dilating  the  cervix,  none  is  so  rapid  as  that  carried  out  by  means  of 
expansile  metal  dilators. 

Pronged  dilators  are  of  ancient  date,  and  at  different  times  have 


Fig.  205. — Pomeroy's  Metreurynter. 


been  brought  forward  and  advocated.  The  most  recent  revival  of  the 
instrument  occurred  in  1890,  when  Bossi  introduced  the  one  which 
in  the  last  three  or  four  years  has  been  so  much  discussed.  Bossi's 
instrument  consisted  of  three  prongs,  but  later  a  fourth  was  added 
(Fig.  208).  Frommer's  modification  of  the  instrument  consists  of 
eight  prongs,  which  theoretically  was  considered  a  distinct  improve- 
ment, for  it  allowed  of  pressure  being  more  equally  distributed  round 
the  margin  of  the  os.  In  practice,  however,  in  common  with  others, 
I  found  it  inferior,  for  it  did  not  allow  the  operator  to  get  his  fingers 
between  the  prongs  to  feel  how  the  cervix  was  stretching.  The  only 
real  improvement  in  Bossi's  latest  pattern  is  De  Seigneux's  instru- 
ment,1 with  its  graduated  caps  and  pelvic  curve  (Fig.  209).     A  very 

1  Zent.  f.  Gyn.,  1905,  p.  717. 


m 


OPERATIVE  MIDWIFER1 


simple  dilator  is  the  eoarteur  of  Tarnier  (Fig.  210),  which  slowly 
expands  by  the  steady  compression  of  the  elastic  hands  at  the  end  of 
the  handles. 

The  operation  of  dilating  the  cervix  with  expansile  metal  dilators 
is  not  difficult.  There  is,  however,  great  danger  of  tearing  the  cervix, 
and  it  is  upon  the  extent  and  frequency  of  this  occurrence,  as  we  shall 
see,  that  criticism  must  be  based. 


Fig.  206. — Champeticr  de  Ribes'  Bag  fully  expanded. 

The  preparation  of  the  patient  is  as  for  any  vaginal  operation. 
She  should  be  deeply  anaesthetized,  otherwise  the  shock  is  consider- 
able. The  blades  of  the  instrument  should  then  be  passed  through 
the  os.  The  os  must,  therefore,  be  sufficiently  dilated  to  allow  of 
this  being  done.  I  would  not  advise  employing  the  instrument  with- 
out the  caps  unless  there  are  no  Hegar's  dilators  at  hand.     "When  the 


FlG.  207. — Cliampetier  de  Ribes'  Metreurynter  (collapsed),  with  Forceps  for  introducing  it. 


cervix  is  obliterated  there  is  no  difficulty  in  getting  the  instrument 
introduced ;  but  when  it  is  still  not  taken  up  there  is  considerable 
difficulty.  Most  operators  are  now  agreed  that  the  instrument  is 
unsuitable  in  these  latter  cases.  If  it  is  employed,  especial  care  must 
be  taken  to  have  the  edge  of  the  flange  on  the  cap  well  beyond  the 
internal  os.     I  do  not  advise  the  seizing  of  the  cervix  with  vulsellum 


ACCOrCJIKMKXT   KOIiCK 


Um 


forceps  while  the  blades  are  being  introduced,  for  by  pulling  on  the 
cervix  one  elongates  it,  and  so  renders  the  introduction  of  the  flanges 
beyond  the  os  internum  difficult. 

By  pressing  the  instrument  well  back  against  the  perineum,  the 
prongs  slip  into  their  places  more  readily. 

Having  placed  the  instrument  in  position,  as  described,  the  handle 


^^^    fes^    fe^X-    >-^££j 

Fig.  208.—  Bossi  Fronged  Dilator  (Open). 


which  expands  the  blades  should  be  turned.  This  must  be  done 
very  slowly,  and  only  in  the  intervals  between  the  pains.  I  usually 
turn  the  handle  not  more  than  a  sixth  of  a  circle  at  a  time,  and  at 
the  later  stages  even  less  than  that.  One  should  always  desist  during 
a  uterine  contraction,  and  even  sometimes  turn  the  handle  backwards, 
to  take  the  strain  off  the  cervix  for  a  moment  or  two.  Every  now 
and  again,  also,  one  should  feel  between  the  prongs  how  the  cervix  is 


Fig.  209. — De  Seigneux's  Uterine  Dilator. 


yielding,  both  on  the  cervical  and  vaginal  surfaces.  In  my  experience, 
when  tears  have  occurred,  they  hare  always  taken  place  in  the  lateral 
walls,  and  usually  first  on  the  cervical,  not  on  the  vaginal  surface. 
I  remember  one  case  in  which  a  bad  laceration  occurred,  when  I 
suddenly  felt  the  resistance  of  the  cervix  disappear.  I  found  no  tear 
in  the  vaginal  surface,  but  a  moment  or  two  afterwards  it  was  also 

30 


mi; 


Ol'KHATIYE  MIDWIFERY 


found  torn.  The  graduated  caps  of  Seigneux's  instrument  without 
doubt  give  a  wide  surface  of  pressure,  and  to  some  extent  lessen  the 
risk  of  tearing. 

The  time  taken  to  screw  up  the  instrument  to  the  required  amount 
depends  upon  the  condition  of  the  cervix.  If  it  is  a  flabby  cervix, 
twenty  minutes  may  suffice  ;  but  if  it  is  hard,  and  especially  if  it  is 
not  taken  up,  more  than  twice  that  amount  of  time  may  be  necessary. 
It  is  only  after  some  experience  that  one  can  gauge  this  properly ;  at 
first  one  is  liable  to  be  in  too  great  a  hurry.  I  have  not  said  any- 
thing about  changing  the  position  of  the  instrument  so  as  to  alter 
the  points  at  which  the  caps  press  on  the  cervix,  as  has  been 
recommended  by  some  writers,  for  the  latest  instruments  have  a  pelvic 
curve. 

The  extent  of  dilatation  required  depends  entirely  upon  the  size 


Fig.  210. — Ecarteur  of  Tarnier. 


of  the  foetus.  When  the  index  is  at  10,  one  may  usually  stop,  unwind 
the  handle,  and  remove  the  instrument,  for  such  dilatation  will  permit 
a  small  child  readily  passing  through. 

After  removal  of  the  instrument,  one  should  note  very  carefully  ij 
there  are  any  lacerations,  for  there  is  no  doubt  that  main/  of  the  tears 
which  follow  this  method  of  accouchement  force'  result,  not  from  the 
dilatation,  but  from  the  subsequent  extraction  of  the  child. 

Such,  briefly,  is  the  method  of  employing  expansile  metal  dilators. 
Many  have  found  them  "most  valuable.  Doubtless  the  more  enthu- 
siastic have  been  inclined  to  overestimate  their  importance,  and  to 
practically  place  no  restriction  upon  their  employment,  just  as  others 
condemn  them  utterly.  Amongst  those  who  have  tried  to  take  an 
unbiassed  view,  and  who  have  had  some  considerable  experience  of 
the  different  varieties  of  dilators,  opinions  are  pretty  uniform  regard- 


ACCOUCHEMENT  FORCE  467 

ing  the  dangers,  and  how  these  are  to  be  avoided.      The  principal 
danger  is  laceration  of  the  cervix. 

Writing  on  the  subject  in  November,  1903, x  I  mentioned  four 
factors  which  influenced  the  occurrence  of  laceration  : 

(a)  The  manner  in  which  the  dilatation  is  carried  out. 

(b)  The  number  of  the  pregnancy. 

(c)  The  degree  to  which  the  cervix  has  been  taken  up. 

(d)  The  age  of  the  pregnancy. 

At  the  present  time,  with  a  very  much  more  extensive  experience 
of  cases  from  hospital  and  private  practice,  I  still  am  of  opinion  that 
these  are  the  most  important  factors.  I  am  now  inclined  to  dilate 
much  more  slowly,  and  the  most  recent  experience  of  obstetricians  is 
the  same.  It  should  always  be  remembered  that  Bossi  recommended 
twenty  minutes  up  to  one  and  a  half  hours.  Then,  again,  although 
as  a  rule  the  cervix  of  a  multipara  yields  better  than  that  of  a  primi- 
para,  if  there  are  deep  cervical  lacerations  from  former  labours,  these 
tear  very  rapidly,  and  often  before  much  dilatation.  On  two  occasions 
I  have  witnessed  this.  On  one  occasion  the  laceration  which  resulted 
while  I  was  dilating  extended  into  the  lower  segment,  and  had  to  be 
packed  with  gauze  before  the  haemorrhage  could  be  arrested. 

But  the  other  two  factors  are  the  most  important — the  degree  of 
dilatation  of  the  cervix  and  the  age  of  the  pregnancy.  With  a  patient 
in  labour  and  the  cervix  '  taken  up,'  dilatation  with  Bossi's  or  any 
other  metal  dilator  is  not  difficult,  and  lacerations  should  be  very 
infrequent  and  very  slight.  Some  say,  Why  not  use  the  hands  in  such 
cases  ?  Of  course,  there  is  no  possible  objection  to  doing  so  ;  but  it  is 
infinitely  more  fatiguing  for  the  operator,  and  is  much  slower. 

When  the  cervix  is  closed,  and  not  taken  up,  it  is  a  very  different 
matter,  and  there  is  a  general  opinion  now  that  metal  dilators  are 
unsuitable  in  such  cases.  Even  if  care  and  time  be  taken,  the  danger 
of  severe  lacerations  is  very  great ;  besides,  the  extraction  of  the  child 
is  often  difficult,  for  the  cervix  grasps  the  child  whenever  traction  is 
made  upon  it.  The  condition  of  the  cervix  should  guide  one.  If  it  is 
soft  and  dilatable,  then  Bossi's  instrument  may  in  a  few  cases  be 
employed  safely.  If,  on  the  other  hand,  it  is  hard  and  rigid,  and  the 
uterus  must  be  emptied  quickly,  I  would  strongly  advise  against 
employing  it. 

But  quite  as  important,  although  not  as  a  rule  so  much  appre- 
ciated, is  the  age  of  the  pregnancy.  The  earlier  the  pregnancy,  the 
greater  the  difficulty  in  dilating  the  cervix  ;  so  much  so  that  unless  it 

1  Trans.  Glas.  Obst.  Soc,  vol.  iv.,  p.  167. 


168  OPERATIC  E  M1DW1I  i:i;V 

happens  bo  be  abnormally  soft,  I  have  given  up  using  metal  dilators  in 
the  earlier  months,  and  have  chosen  instead  vaginal  ('a  san  ion. 

The  results  obtained   with   metal  dilators  in   this  country— tb 
tor  example,  of  Fothergill,  Haultain,  Ballantyne,  Jardine,  Armstrong, 

and  others — are  very  satisfactory,  especially  in  cases  where  they  are 
employed  when  the  cervix  has  heen  taken  up.  The  later  figures  from 
Leopold's  Clinic  in  Dresden — those  furnished  by  Ehrlich1 — are  also 
good.  He  puts  severe  laceration  as  only  occurring  in  1  per  cent.  <>f 
cases.  There  were,  however,  five  not  included  where  the  laceration 
wTas  quite  decided,  although  not  severe.  A  most  interesting  paper  by 
Lichtenstein,2  taking  up  the  later  effects  of  dilatation  with  metal  dilators 
in  Leopold's  Clinic,  appeared  a  few  years  ago.  It  was  an  answer  to 
Bardelehen's  unfavourahle  criticism  of  the  treatment.  Lichtenstein 
succeeded  in  getting  eighteen  of  the  old  cases  to  come  hack  and  be 
most  carefully  examined.  The  two  cases  in  which  there  had  heen  a 
severe  laceration  had  healed  fairly  satisfactorily.  "With  few  excep- 
tions, the  women  were  remarkahly  well.  Some  had  slight  catarrh, 
and  one  had  retroflexion  ;  but  such  occurrences  may  follow  even 
normal  labours.  There  was  n<>  evidence  t<>  show  that  expansile  dilators 
judiciously  employed  caused  future  uterine  disturbances. 

In  the  discussions  on  the  subject,  which  took  place  at  the  Ver- 
sammlung  der  deutschen  Gessellschaft  fur  Gynaecologie  in  1907, 
and  at  the  annual  meeting  of  the  British  Medical  Association  in  the 
same  year,  all  who  favoured  metal  dilators  restricted  them  to  cases 
in  the  later  weeks  of  pregnancy  where  the  cervix  had  heen  already 
taken  up. 

Enlarging1  the  Cervical  Canal  by  Means  of  Incisions. 

Incisions  of  the  Cervix. — Before  considering  the  latest  and  most 
extensive  method  of  incising  the  cervix,  known  as  vaginal  Cesarean 
section,  I  must  refer  briefly  to  the  small  incisions  of  the  cervix  which 
have  been  employed  from  early  times  in  certain  conditions,  as,  for 
example,  rigidity  of  the  cervix,  and  atresia  of  the  cervix.  It  is  a 
matter  of  historical  interest  that  such  incisions  were  recommended 
by  Simpson3  and  others  for  uterine  and  vaginal  carcinoma  obstructing 
the  parturient  canal.  In  atresia  of  the  os  externum  we  have  seen  that 
a  cervical  incision  should  he  made  over  the  os,  and  labour  allowed  to 
proceed.  In  rigidity  of  the  cervix,  when  that  condition  does  not 
yield  to  opium  or  chloral,  or  the  local  application  of  cocaine,  multiple 

1  Archivf.  Gyn.,  1904,  Bd.  Ixxiii.,  Heft  :;,  p.  439. 
-   Ibid.,  1905,  Bd.  Ixxv.,  Heft  1,  p.  1. 
3  'Obstetric  Works,'  vol.  i.,  p.  198. 


ACCOUCHEMENT  FORCE 


469 


small  incisions  with  scissors  are  .usually  recommended.     Sometimes 
these  are  sufficient,  but  on  other  occasions  they  are  not,  and  deeper 


FlG.  211. — Incision  of  the  Cervix  where  the  latter  is  taken  up,  but  the  Os  Externum  is  only 

slightly  dilated. 

Dark  lines  show  direction  in  which  incisions  should  he  made. 


incisions  have  to  be  made.     These,  however,  should  only  be  employed 
if  the  cervix   is   completely  taken    up.     The  illustration   (Fig.  211) 


470 


OPERATIVE  MIDWIFERY 


explains  the  direction  of  the  incisions.  Prior  to  employing  them, 
the  vagina  and  vulva  are  cleansed,  as  has  been  described,  and  the 
patient  placed  in  the  lithotomy  position,  and  brought  over  to  the  edge 
of  the  conch. 

The  advantage  of  this  method  of  operation  is  that  the  uterus  can 
be  rapidly  emptied,  and  with  less  shock  than  when  a  metal  dilator  or 


FlG.  212.— The  Two  Vulsellum  Forceps  applied  to  the  Cervix. 
The  dotted  lines  show  direction  of  incisions.     (The  Year- Book  Publishers.) 

the  hands  is  employed.     In  certain  cases — e.g.,  valvular  disease  of  the 
heart — this  question  of  shock  is  a  very  important  one. 

Vaginal  Caesarean  Section. — Within  the  last  few  years  incisions 
of 'a  very  much  more  extensive  nature  have  been  under  consideration. 
The  names  of  two  obstetricians  are  connected  with  the  subject — 
Diihrssen  and  Acconci.  I  do  not  intend  considering  who  should  have 
priority.  Those  interested  in  the  question  will  find  it  fully  discussed 
by  Diihrssen.1  Since  Acconci's  death,  Di'ihrssen's  name  has  come  to 
i    Winckel'a  '  Handbuch/  1900,  lid.  iii.,  Teil  ii.,  p.  609. 


ACCOUCHEMENT  FORCE  471 

be  almost  universally  associated  with  the  operation.  He  first  described 
it  in  1895.  His  monograph,  entitled  '  Der  Vaginale  Kaiserschnitt,' 
appeared  the  following  year.  Since  then  he  has  published  other 
papers,  and  made  many  communications  on  the  subject.  The 
operation  is  commonly  known  as  vaginal  Cesarean  section,  and 
certainly,  from  Diihrssen's  description  of  the  extensive  incisions  he 


Fig.  213.— Pushing  the  Bladder  from  Anterior  Uterine  "Wall.    (The  Year-Book  Publishers.) 

makes,  it  must  be  admitted  that  the  name  given  to  it  is  not  out  of 
keeping  with  the  magnitude  of  the  operation.1 

The  ease  or  difficulty  in  performing  the  operation  of  vaginal 
Cesarean  section  depends  chiefly  upon  the  size  of  the  uterus  and  the 
age  of  the  pregnancy.  In  the  first  half  of  pregnancy  the  uterus  can 
be  pulled  down,  and  the  uterine  contents  removed  through  a  much 
smaller  opening  than  is  necessary  if  the  pregnancy  is  more  advanced. 

1  The  terra  'vaginal  Cesarean  section'  is  an  old  one;  it  was  considered  unsuit- 
able by  Baudelocque  (Heath's  translation,  vol.  iii.,  p.  351). 


472 


OPERATE  i:  Mll-WH  Kl;Y 


I  will  first  describe  the  operation  for  the  simpler  cases,  and  then 
inchoate  the  more  extensive  incisions  which  may  he  necessary  when 
the  fu'tus  has  to  he  removed  in  the  later  weeks  of  pregnancy. 

The  patient  is  placed  in  the  lithotomy  position,  and  the  vulva  and 
vagina  thoroughly  cleansed.  With  a  retractor  the  assistant  pulls 
Lack  the  posterior  vaginal  wall.  The  cervix  is  then  seized  laterally 
by  two  vulsellum  forceps,  which  are  replaced  hy  two  ligatures,  as  the 


Fig.  214. — Edges  of  Uterus  being  drawn  down  and  Scissors  cutting  the  Lower  Uterine 
Segment.    (The  fear-Book  Publishers. 

latter  take  up  less  room.  A  transverse  incision  is  now  made  across 
the  cervix  immediately  below  the  reflection  of  the  bladder.  This  trans- 
verse incision  should  embrace  the  anterior  half  of  the  cervix  (Fig.  212). 
It  is  well  also  to  make  a  longitudinal  incision  when  operating  in  the 
later  weeks  of  pregnancy.  The  bladder  is  then  pushed  out  of  the  way 
with  the  fingers  (Fig.  213),  both  in  the  middle  line  and  at  the  sides. 
It  is  most  important  to  separate  the  bladder  completely.  The  anterior 
cervical  wall,  now  bare,  is  split  up  the  middle  line  by  means  of  scissors 


ACCOUCHE  Mi;  NT  FORCE 


473 


to  the  extent  of  permitting  the^  fingers  being  introduced  into  the 
uterus  (Fig.  214).  The  membranes  now  protrude,  and  if  the  opening 
into  the  uterus  is  of  sufficient  extent,  these  are  ruptured,  and  the 
child  seized  by  a  foot  and  extracted.  Even  with  a  f<etus  of  only 
twenty  weeks  there  may  be  a  little  difficulty  with  the  after-coming 
head;  if  so,  the  head  is  perforated  with  a  pair  of  sharp -pointed 
scissors. 

The  membranes  and   placenta   are  then  removed,  and   ergotine 


Fig.  215. — Continuous  Suture  being  applied.     (The  Year-Book  Publishers.) 


injected,  if  this  has  not  been  done  before  commencing  the  opera- 
tion. An  intra-uterine  douche  of  a  temperature  of  118°  F.  is 
then  given  to  stimulate  the  uterus  to  retract.  If  retraction  is  not 
satisfactory,  the  uterus  should  be  plugged  firmly  with  gauze.  The 
uterine  wound  is  then  stitched,  and  this  is  best  done  with  a  continuous 
catgut  suture  (Fig.  215).  The  carrying  out  of  this  is  greatly  facilitated 
by  making  traction  on  the  ligatures  which  have  been  applied  through 


471  OPERATIC  E  MIDWIFERY 

thf  cervix,  for  they  bring  the  uterine  wound  within  easy  reach,  and 
arrest  any  bleeding  from  the  wound.  As  a  rule  the  catgut  suture  is 
introduced  from  without,  hut  Jhihrssen  recommends  the  application 
and  tying  of  the  ligatures  from  the  cervical  surface.  The  bladder  La 
then  pulled  back  and  tacked  into  position,  and  the  edges  of  the 
vaginal  wound  united.  If  it  is  the  pleasure  of  the  operator,  a  small 
strip  of  gauze  may  be  inserted  in  front  of  the  cervix  to  act  as  a  drain. 
This  strip  of  gauze  and  the  gauze  in  the  uterus,  if  they  have  been 
inserted,  are  removed  in  twenty-four  hours. 

When  the  operation  has  to  be  performed  in  the  later  weeks  of 
pregnancy  more  extensive  incisions  of  the  cervix  are  necessary. 
Bumrn  has  found  the  splitting  of  the  anterior  uterine  wall  sufficient 
-even  in  these  cases,  but  Diihrssen  recommends  an  incision  of  the 
posterior  wall  also.  The  latter  operator  proceeds  as  follows :  The 
resistance  of  the  lower  third  of  the  vagina,  in  the  case  of  a  primipara, 
is  removed  by  a  right-sided  vaginal  and  perineal  incision.  If  by  this 
incision  the  levator  ani  is  cut  through,  a  large  fist  can  be  introduced 
into  the  vagina,  and  the  vaginal  vault  and  the  vaginal  portion  of  the 
cervix  readily  brought  into  view  by  means  of  short,  broad  retractors ; 
these  arrest,  by  compression,  any  bleeding  from  the  wound.  The 
vaginal  portion  of  the  cervix  is  then  seized  laterally  by  two  vulsellum 
forceps,  which  are  then  replaced  by  two  threads,  and  the  posterior 
lip  of  the  cervix  incised  as  high  up  as  the  insertion  of  the  vagina. 
The  posterior  vaginal  vault  is  then  divided  transversely,  and  a 
retractor  pushed  through  the  opening.  The  peritoneum  in  the  pouch 
of  Douglas  is  then  pushed  off  the  posterior  vaginal  wall.  In  the 
manner  already  described,  the  anterior  vaginal  vault  is  divided,  and 
the  bladder  pushed  out  of  the  way.  One  has  then  the  w7hole  of  the 
anterior  and  posterior  cervical  walls  laid  bare.  The  anterior  and 
posterior  uterine  wounds  are  then  extended.  The  opening  through 
which  the  membranes  protrude,  if  they  are  still  intact,  must  be  so 
large  as  to  allow  the  easy  passage  of  a  large  fist.  The  membranes 
are  then  ruptured,  a  foot  seized,  and  the  child  extracted.  If  the 
uterus  is  well  retracted  one  may  wait  until  the  placenta  separates.  If 
the  uterus  does  not  retract  sufficiently,  the  placenta  must  be  removed 
naturally,  and  a  hot  douche  given.  Should  this  not  be  sufficient,  the 
uterus  must  be  plugged.  This  is  very  easily  carried  out,  as  the  two 
broad  retractors  can  be  placed  against  the  opening  into  the  uterus, 
and  between  them  a  large  quantity  of  gauze  introduced.  The  anterior 
and  posterior  wounds  are  then  carefully  stitched,  as  already  described, 
and  the  bladder  brought  down  into  position.  If  need  be,  a  gauze  drain 
is  inserted  behind  and  in  front  of  the  cervix.  If  a  vaginal  perineal 
incision  has  been  made,  the  stitching  of  it  completes  the  operation. 


ACCOUCHEMENT  FORCE  175 

This  should  be  done  by  stitching  the  vagina  with  catgut  and  the 
perineum  with  silkworm-gut  sutures. 

Such  is  the  latest  obstetric  operation,  one  which  all  must  admit  is 
of  great  magnitude,  and  requires  considerable  experience  in  vaginal 
technique.  So  far  it  has  not  received  much  support  in  this  country, 
although  Wilson,  Savage,  myself,  and  a  few  others,  have  practised  it. 
The  same  also  applies  to  America  and  France ;  even  in  Germany 
there  are  several  who  are  opposed  to  it,  although  a  number  of  the 
most  distinguished  obstetricians  favour  it,  as,  for  example,  Bumm, 
Everke,  Kronig,  and  Veit. 

My  experience  of  vaginal  Cesarean  section  has  convinced  me  that 
the  operation  is  one  of  very  great  value,  and  is  a  most  important 
addition  to  obstetric  surgery.  I  have,  therefore,  no  sympathy  with 
those  who  condemn  vaginal  Cesarean  section.  I  am  quite  convinced 
it  is  an  operation  which  has  its  place  in  obstetric  practice,  and  I  would 
mention,  in  support  of  my  contention,  the  views  expressed  recently  by 
Olshausen,1  who  is  always  broad-minded  in  his  attitude  towards 
gynaecological  and  obstetrical  problems.  I  do  not  for  a  moment  doubt 
the  operation  is  employed  far  too  extensively  in  some  quarters.  That 
always  follows  the  introduction  of  any  new  treatment ;  but  that  will 
soon  be  righted,  and  the  operation  relegated  to  its  proper  place. 

As  the  operation  is  so  emphatically  condemned  by  some  and  so 
enthusiastically  recommended  by  others,  I  purpose  giving  here  only 
my  own  views  and  experience. 

When  vaginal  Cesarean  section  was  first  introduced  I  was  at 
once  impressed  by  the  sound  surgical  principles  that  the  operation 
■embodied.  Prior  to  that  time  all  methods  of  rapidly  enlarging  the 
cervical  canal  were  crude  and  unsurgical.  Secondly,  it  was  at  once 
apparent  that  by  means  of  this  operation  one  could  empty  the  uterus 
in  a  few  minutes,  and  so  deal  with  certain  cases  that  would  be  lost 
by  employing  the  older  and  very  much  slower  methods  of  dilating 
the  cervix. 

Being  impressed  with  the  operation,  I  determined  to  perform  it 
when  a  suitable  case  presented  itself.  After  waiting  some  years,  a 
case  I  deemed  suitable  was  admitted  into  the  hospital. 

A  3-para,  about  five  months  pregnant,  was  admitted  to  the  Glasgow 
Maternity  Hospital  under  my  care  in  October,  1903,  on  account  of  persistent 
vomiting.  Every  medicinal  remedy  had  been  tried  without  success.  With 
absolute  rest  in  bed,  and  feeding  by  the  bowel,  the  sickness  was  arrested, 
but  whenever  one  attempted  to  feed  her  by  the  mouth  the  sickness  returned. 
One  evening  my  house  surgeon  informed  me  that  the  patient  had  become 
very  ill,  and  that  he  was  most  anxious  about  her.     When  I  reached  the 

1  Zent.f.  Gyn.,  1905,  p.  805. 


476  (H'I.i;ati\  i:  midwii  id;v 

hospital  a  little  later  I  Found  her  extremely  collapsed,  with  a  feeble  pulse  of 
about  L60.  Although  1  had  very  little  hope  of  saving  her,  I  determined  to 
empty  the  uterus. 

After  an  injection  of  ^  grain  strychnine  she  was  anssthetized  with  a 
mixture  of  ether  and  chloroform.  Examining  vaginally,  1  found  the  cervis 
completely  closed.  With  a  little  difficulty  I  succeeded  in  passing  ELegar'e 
dilators,  up  to  No.  10.  I  could  not,  however,  introduce  a  larger  size, 
although  1  repeatedly  tried  to  do  so.  I  decided,  therefore,  that  the  only 
course  was  to  split  open  the  cervix.  This  I  did  without  any  difficulty,  in 
the  manner  already  described.  In  a  very  short  time  the  uterus  was  com- 
pletely emptied  and  douched  out,  the  cervix  stitched,  and  the  patient  put 
back  to  bed.  She  made  an  uninterrupted  recovery,  and  the  cervical  wound 
healed  perfectly. 

As  a  contrast  to  the  ease  with  which  the  uterus  was  emptied  in  the 
above  case,  let  me  describe  two  others  seen  in  consultation,  where  a 
different  treatment  was  pursued  : 

Case   1. — One  morning  I  was  asked  by  Dr.  M to  see  a  case  of 

persistent  vomiting  in  a  young  married  lady  of  twenty-six  years,  who,  as  far  as 
could  be  calculated,  was  twelve  weeks  pregnant.  The  late  Dr.  K.  S.  Thomson 
was  also  called  in  consultation.  After  considering  the  case  most  carefully, 
we  agreed  to  temporize,  and  to  feed  her  entirely  by  the  rectum.  For  a 
few  days  she  improved,  but  at  the  end  of  a  week  it  became  evident  that  she 
was  becoming  weaker,  and  that  the  only  hope  of  saving  her  lay  in  emptying 
the  uterus.  She  was  by  this  time  extremely  emaciated,  with  a  pulse  of  1 40 
and  a  temperature  of  100°.  Under  an  anaesthetic  I  found  I  could  only  dilate 
the  cervix  to  admit  a  No.  10  Hegar.  I  consequently  packed  the  cervix  and 
vagina.  Fully  twenty-four  hours  later  I  removed  the  packing,  and  found 
the  cervix  very  little  softer.  With  great  difficulty,  and  after  nearly  an 
hour's  labour,  I  succeeded  in  dilating  the  cervix  to  permit  of  me  removing 
the    ovum.     During   the   night   following   the   operation    the   patient    had 

frequent  attacks  of  syncope,  and   Dr.   M ,  who  remained   with  her  all 

night,  was  extremely  anxious  about  her.    She  ultimately  made  a  good  recovery. 

Case  2. — I  was  called  to  a  neighbouring  town  by  Dr.  F ,  to  see  a 

young  married  lady,  three  months  pregnant,  extremely  collapsed  by  reason 
of  excessive  vomiting.  Everything  had  been  tried,  but  without  avail.  Her 
condition  was  very  critical.  She  was  very  thin  and  emaciated,  and  her  pulse 
was  130  and  of  very  poor  tension.  We  were  both  satisfied  that  the  uterus 
must  be  emptied.  When  she  was  anaesthetized  I  proceeded  to  dilate  the 
cervix,  and,  as  before,  found  it  would  only  dilate  to  the  extent  of  No.  !<• 
Hegar.  I  therefore  packed  the  cervix  and  vagina.  The  following  day  I 
removed  the  packing,  and  found  the  cervix  only  a  little  softer.  Hiving 
now  my  assistant  and  two  nurses,  I  decided  to  perform  vaginal  Caesarean 
ion.  This  was  done  without  difficulty,  and  the  uterus  was  emptied  in  a 
few   minutes.     The  cervix   was  then  carefully  stitched,  and  the  woman  put 

back  to  bed.     She  rallied  for  a  little  after  the  operation,  but,  unfortunately, 

died  some  eight  hours  later. 


ACCOUCHEMENT  FORCE  177 

As  a  result  of  several  cases  in  which  vaginal  Cesarean  section 
has  proved  highly  successful,  and  with  the  experience  of  the  last  two 
recorded  cases  and  of  others  of  a  like  nature,  I  am  convinced  that  up 
to  the  twenty-fifth  /red;  the  opera/ion  under  consideration  is  tin-  best 
way  of  rapidly  emptying  the  uterus.  By  adopting  it  shock  is  lessened, 
and  repeated  anaesthesia,  so  fatal  in  such  cases,  is  avoided. 

There  is  one  disadvantage  which  the  operation  possesses.  In  the 
first  place,  it  is  not  suitable  for  ordinary  practice,  as  at  least  two 
assistants  are  necessary,  one  to  give  the  anaesthetic  and  the  other  to 
help  the  operator.  Some  may  put  forward  another  objection — that 
the  uterine  cicatrix  may  give  way  at  a  subsequent  parturition,  but 
the  results  of  recorded  cases  in  which  there  have  been  subsequent 
labours  give  no  support  to  this  objection.  Why  should  the  cicatrix 
yield  ?  A  well-stitched  uterine  incision  heals  with  the  minimum  of 
cicatricial  tissue. 

In  the  later  week*  of  pregnancy,  when  the  uterus  has  to  be  emptied 
rapidly,  I  am.  not  convinced  that  vaginal  Ccesarean  section  is  suitable, 
or  so  sound  in  principle  as  operating  by  the  abdominal  route.  The 
uterus  in  the  later  weeks  of  pregnancy  is  anatomically  very  different 
to  that  in  the  earlier  weeks.  In  the  later  weeks  the  lower  uterine 
segment  is  already  formed,  and,  if  the  vaginal  route  is  chosen,  a  large 
body  has  to  be  rapidly  pulled  through  a  canal  which,  even  after 
extensive  incisions,  is  imperfectly  dilated.  The  part  of  this  canal 
which  will  suffer  most  injury  is  the  lower  uterine  segment,  which  is 
very  easily  torn.  My  personal  experience  of  the  vaginal  operation  in 
the  later  weeks  of  pregnancy  supports  these  theoretical  objections,  so 
that  I  prefer  the  abdominal  route  in  such  cases. 

The  Extraction  of  the  Child  after  Dilatation  of  the  Cervix. — 
Naturally,  version  is  the  simplest  method  of  delivering  a  very  prema- 
ture foetus.  When,  however,  the  fcetus  is  viable,  the  choice  lies 
between  version  and  forceps.  Most  operators  prefer  version,  and  I 
think  it  is  the  best  procedure  if  there  is  no  chance  of  saving  the  child, 
for  one  can  perforate  the  after-coming  head  and  complete  the  delivery 
more  easily  than  with  forceps.  If,  however,  the  child  is  alive,  and 
likely  to  survive,  forceps  should  be  employed,  as  the  foetal  mortality 
is  lower  than  if  version  is  employed. 


CHAPTER  XXIX 

OPERATIONS    INVOLVING    DESTRUCTION    OF    THE    CHILD: 

CRANIOTOMY— DECAPITATION— EVISCERATION— 

CLEIDOTOMY 

The  operations  which  we  must  now  consider  have  for  their  object  the 
diminution  of  the  bulk  of  the  child,  in  order  to  permit  of  its  more 
easy  passage  through  the  parturient  canal.  They  are  often  termed 
'  destructive,'  but  in  the  present  position  they  hold  in  obstetric 
surgery  this  term  is  not  so  applicable  as  formerly,  as  they  are  per- 
formed only  in  exceptional  cases  upon  a  living  child.  The  operations 
which  come  under  discussion  are  Craniotomy,  Decapitation,  Eviscera- 
tion, and  Cleidotomy.     I  will  deal  with  them  in  the  order  mentioned. 

Craniotomy. 

The  operation  of  craniotomy  is  of  great  antiquity.  In  former 
years  it  was  most  laborious,  for  the  instruments  employed  were  of 
rude  form  and  workmanship.  Indeed,  those  employed  for  the  extrac- 
tion of  the  child,  which  consisted  of  hooks  of  various  devices  and 
a  simple  form  of  toothed  forceps,  were  quite  inadequate  for  the 
purpose. 

It  is  really  only  within  recent  years  that  the  operation  has 
been  simplified  and  rendered  thoroughly  scientific,  and  this  has  in 
great  part  resulted  from  the  perfecting  of  the  three-bladed  cephalo- 
tribe.  I  put  this  in  the  forefront  of  my  remarks,  because  I  find 
from  several  current  English  text-books  this  instrument  is  not  fully 
appreciated.  Only  a  few  years  ago  the  reviewer  of  a  most  excellent 
American  treatise  on  obstetrics  in  one  of  our  best-known  weekly 
medical  journals  questioned  the  advantages  possessed  by  the  three- 
bladed  instrument.  I  cannot  understand  how  anyone  who  has  used 
this  instrument  can  fail  to  be  impressed  by  its  excellence.  In  the 
Glasgow  Maternity  Hospital  we  have  used  it  for  the  last  twelve  years. 

478 


OPEBATIONS  INVOLVING  DESTRUCTION  OF  CHILD     479 

The  Indications  for  the  Operation  of  Craniotomy.  —  Before 
discussing  in  detail  the  indications  and  limitations  of  the  operation 
of  craniotomy,  let  me  say  a  few  words  regarding  the  question  of 
perforating  a  living  child — a  question  which  has  interested  obstetricians 
in  all  ages.  Even  at  the  present  day  there  is  no  uniformity  of 
opinion,  for  on  the  one  hand  are  those  who  would  lightly  destroy 
the  child,  and  consider  only  the  mother,  while  on  the  other  hand 
one  has  such  a  distinguished  obstetrician  as  Pinard  emphatically 
stating  that  under  no  circumstances  should  a  living  child  be  sacri- 
ficed. I  refer,  of  course,  only  to  the  child  which  is  mature,  or 
nearly  so. 

I  have  frequently  cautioned  my  readers  against  taking  up  an 
extreme  position  with  regard  to  any  of  the  obstetric  operations,  and 
here  again,  in  this  matter  of  perforating  a  living  child,  I  would  point 
out  that  there  is  a  middle  course,  and  that  it  is  sometimes  in  the  best 
interests  of  the  mother,  the  family,  and  of  the  State  to  destroy  the 
living  child.  A  healthy  mother's  life  is  of  more  value  to  the 
family  than  an  infant's.  If  the  mother  is  young,  her  prospects  of 
life  are  much  better  than  is  the  child's,  and  she  may  produce  more 
children.  In  addition,  it  must  not  be  forgotten,  if  the  child's  life  has 
been  endangered  by  a  labour  which  has  been  long  protracted,  the 
chances  of  its  surviving  are  very  uncertain.  I  am  in  the  habit  of 
teaching,  in  cases  of  great  disproportion  between  fcetal  head  and  pelvis,, 
that  it  is  justifiable  to  destroy  a  living  child  under  the  following 
circumstances : 

(a)  When  the  child  is  hydrocephalic. 

(6)  When  the  child  is  on  the  point  of  dying,  as  indicated  by  the 
condition  of  its  heart  sounds  or  the  pulsations  in  its  cord. 

(c)  When  extraction  with  forceps  has  failed,  and  symphysiotomy 

or  pubiotomy  is  deemed  unsuitable. 

(d)  When  there  is  a  probability  that  the  parturient  canal  has 

become  already  infected. 

All  obstetricians  will  agree  regarding  the  case  of  the  hydrocephalic 
child.  If  any  operator  should  have  qualms  about  performing  the 
operation  in  such  a  case,  he  may  tap  the  head  either  through  the 
presenting  fontanelle  or  through  the  spinal  column,  if  the  child 
presents  by  the  breech  (Chapter  VI.). 

But  it  is  regarding  perforating  a  living  child  in  the  three  other 
conditions  that  the  greatest  differences  of  opinion  exist.  I  may  state, 
however,  that  many  operators  hold  the  same  views  regarding  these 
matters  as  here  stated.  Certainly  I  know  of  no  English  obstetrician 
who  takes  up  an  essentially  different  position.  WThat  prospect  is  there 
of  delivering  by  Cesarean  section,  symphysiotomy,  or  pubiotomy,  a 


180  OPERATIVE  MIDWIFERY 

child  that  will  survive  if  its  fotal  heart  is  extremely  embarrassed? 
Before  the  patient  could  lie  prepared  for  Cesarean  section  or  extrac- 
tion could  ho  made  after  symphysiotomy  or  pubiotomy,  the  child 
would  almost  certainly  be  dead.  Again,  as  regards  the  two  other 
conditions  where  forceps  delivery  has  been  attempted,  version  per- 
formed, or  where  the  canal  is  already  infected  by  previous  examination 
by  midwife,  handy  woman,  or  careless  medical  attendant,  what  is  the 
prognosis  as  regards  the  mother  and  child?  It  is  extremely  bad. 
CsBsarean  section  performed  under  any  of  these  latter  conditions  is 
attended  with  an  enormous  maternal  mortality,  something  between 
20  and  30  per  cent.,  and  symphysiotomy  and  pubiotomy  are  little 
better.  In  the  Glasgow  Maternity  Hospital  so  bad  were  our  maternal 
results  that  we  have  ceased  to  perform  Cesarean  section  in  such 
cases,  and  in  many  of  the  Continental  clinics  the  same  position  is 
taken  up.  This  matter  is  considered  more  fully  in  the  chapter  on 
Cesarean  Section  (Chapter  XXVI.). 

As  regards  the  ethical  and  legal  aspects  of  the  subject  I  offer  no 
opinion.  There  are  no  hard-and-fast  ethical  rules,  nor  are  there  any 
definite  laws  on  the  subject.  If  the  matter  were  put  before  a  com- 
mittee of  representatives  of  the  medical  and  legal  professions  and 
■educated  lay  public,  I  feel  certain  the  opinion  would  be  given  un- 
hesitatingly that  the  mother's  life  must  never  be  unduly  endangered, 
■and  that  it  is  sometimes  right  to  destroy  a  living  child. 

In  one  respect  the  operation  of  craniotomy  is  too  seldom  performed 
by  the  general  practitioner.  How  seldom  does  he  have  recourse  to 
craniotonry,  even  although  he  knows  the  child  is  dead  !  Instead,  he 
prefers  to  drag  the  child  from  the  parturient  canal  with  forceps.  I 
have  seen  him  often  doing  this,  even  when  the  pulseless  cord  was 
hanging  down  at  the  side  of  the  child's  head. 

Craniotomy  is  an  operation  of  great  simplicity  in  all  cases  except 
those  in  which  the  pelvis  is  extremely  deformed.  With  a  pelvis  of 
small  capacity,  however,  the  operation  becomes  progressively  more 
-difficult,  and  there  comes  a  stage  when  it  becomes  dangerous  to  the 
mother,  and  even  impossible.  The  lowest  limit  at  which  the  opera- 
tion should  be  had  recourse  to  depends  not  only  upon  the  actual 
capacity  of  the  pelvis,  but  upon  its  form,  the  size  and  consistency 
of  the  foetal  head,  and  the  experience  of  the  operator.  Naturally, 
with  a  pelvis  extremely  deformed  in  all  directions,  the  operation  is 
more  difficult  than  when  one  diameter  is  specially  affected.  Thus, 
it  is  more  difficult  in  extreme  degrees  of  general  contraction  and  in 
osteomalacic  pelvis  than  in  flat  pelvis.  Personally,  I  have  always 
looked  upon  2h  inches  (62  centimetres)  as  the  lowest  limit  for 
craniotomy.     Indeed,  even  with  a  conjugata  vera  of  that  size  I  have 


OPERATIONS  INVOLVING  DESTRUCTION  OF  CHILD     481 

often  found  the  operation  very  tedious  and  troublesome,  while  below 
that  figure  it  has  been  one  of  extreme  difficulty.  It  has  been  my 
practice  never  to  perform  the  operation  if  the  conjugata  vera  is  less 
than  2{-  inches,  and  I  only  have  recourse  to  it  with  such  a  pelvic 
deformity  if  the  child  is  dead,  and  I  feel  convinced  that  the  risks  to 
the  mother  from  Cesarean  section  are  extreme,  when,  indeed,  I  can 
hope  for  little  else  than  a  mortality  of  20  to  30  per  cent. 

In  discussing  this  important  matter  of  the  lowest  limit  for  safe 
craniotomy,  one  naturally  can  only  consider  the  results  and  opinions 
of  recent  operators,  for  Cesarean  section  until  quite  recent  times  was 
attended  with  such  an  enormous  mortality  that  craniotomy  was  pre- 
ferred. Even  as  recently  as  1886  Barnes  wrote :  '  I  have  arrived  at 
the  settled  conviction  that  cephalotripsy  is  quite  practicable  with  a 
pelvis  measuring  H  inches  in  the  conjugate  diameter,  and  that  the 
risk  to  the  mother  is  inconsiderable  compared  with  that  attending  the 
Cesarean  section.'1  Few,  I  fancy,  would  express  such  an  opinion  at 
the  present  time.  Herman2  states:  'As  a  general  rule,  a  space  of 
2  by  4  inches  represents  the  minimum  through  which  it  is  prudent 
to  attempt  delivery  by  craniotomy.'  Galabin3  writes  :  '  In  the  higher 
degree  of  pelvic  contraction,  such  as  with  a  conjugata  vera  of  2^  inches 
or  less,  I  regard  Csesarean  section  as  the  easier  operation,  and  to  be 
recommended  in  all  cases.' 

Edgar4  writes:  'I  believe  that  it  is  generally  considered  that 
cranioclasis  and  extraction  through  a  pelvis  represented  by  a  con- 
jugata vera  of  2i  inches  or  under  is  equally  as  dangerous  as  Caesarean 
section.'  Williams5  writes  :  '  Craniotomy  is  positively  contra-indicated 
when  the  conjugata  vera  measures  less  than  5*5  centimetres,  since  in 
such  cases  the  extraction  of  the  child,  even  after  the  skull  has  been 
crushed,  is  attended  by  a  greater  maternal  mortality  than  Cesarean 
section.'  Nagel6  places  the  lowest  limit  at  6'5,  and  states  that  he  has 
perforated  and  successfully  extracted  a  child  where  the  conjugata  vera 
was  6  centimetres  (2-4  inches). 

We  will  take  it,  then,  that  2j  inches  (5'6  centimetres),  roughly 
speaking,  represents  the  very  lowest  limit  for  the  operation,  and  even 
then  it  should  only  be  performed  in  exceptional  cases. 

I  cannot  think  that  it  is  desirable,  as  some  have  suggested,  to 
combine  symphysiotomy  with  craniotomy,  and  I  feel  quite  sure  this  is 
the  view  of  almost  all  obstetricians. 

1  '  Lectures  on  Obstetric  Operations,'  p.  337. 

2  '  Difficult  Labour,'  1902,  3rd  edition,  p.  410. 

3  Brit.  Med,  Journ,,  October  11,  1902,  p.  1124. 

4  '  Practice  of  Obstetrics,'  1903,  p.  974.  5  'Obstetrics,'  1910,  p.  463. 
0  '  Operative  Geburtshiilfe,'  1902,  p.  317. 

31 


482  OPERATIVE   MII>\\  1IT.I;Y 

As  regards  the  indications  for  craniotomy  in  other  conditions  than 
contracted  pelvis,  little  need  be  said.  Obstruction  of  the  parturient 
canal  by  cystic  tumours  of  the  ovary,  myoma  of  the  uterus,  carcinoma 
of  the  cervix,  is  seldom  an  indication  for  this  operation.  It  is  almost 
always  wrong  to  drag  ;t  child,  even  after  craniotomy,  past  obstructions 
produced  by  such  growths.  It  sometimes  happens,  however,  where 
the  rapid  emptying  of  the  uterus  is  of  importance  to  the  mother — as 
in  certain  cases  of  eclampsia,  heart  disease,  etc. — that  perforating 
the  child  facilitates  the  delivery.  In  these  cases  the  operation  should 
only  be  performed  if  the  child  is  dead  or  dying,  or  is  BO  premature 
that  there  is  no  possibility  of  it  living. 

I  need  not  discuss — for  it  is  referred  to  elsewhere — the  operation 
of  craniotomy  in  such  conditions  as  '  locked  twins,'  '  double  monsters,' 
or  hydrocephalus. 

Prognosis.  — The  prognosis  of  the  operation  of  craniotomy  depends 
upon  several  circumstances,  but  the  two  conditions  which  influence 
it  most  are  the  degree  of  pelvic  deformit}',  and  the  previous  operative 
interference  and  probable  infection.  As  can  readily  he  understood, 
the  mortality  becomes  higher  as  the  pelvis  becomes  smaller,  and 
where  frequent  examinations  and  attempts  at  delivery  with  forceps 
have  been  made  before  the  patient  is  subjected  to  the  operation. 

During  the  years  11)01  to  1906  inclusive,  in  the  Glasgow  Maternity 
Hospital,  I  and  my  assistants  performed  the  operation  of  crani- 
otomy sixt}T-three  times  with  eight  deaths,  a  mortality  of  12  6  per 
cent.  This  is  4  per  cent,  higher  than  my  mortality  for  Cesarean 
section.  It  is  entirely  to  be  accounted  for  by  the  fact  that  in  most 
of  the  fatal  cases  the  parturient  canal  was  very  much  injured  and 
invariably  infected  before  the  patient  was  admitted  to  the  hospital. 
It  is  interesting  to  find  that  not  a  single  death  occurred  in  cases  which 
had  been  brought  into  my  wards  uninterfered  with. 

Galabin,  for  Guy's  Hospital,  states  that  from  1891  to  1901  the 
mortality  was  9  per  cent.  ;  in  the  Rotunda  Hospital,  1896  to  1900,  the 
mortality  was  16  per  cent.  Pinard,  from  the  years  1892  to  1899,  places 
it  at  11*5  per  cent.  Liermberger,  in  1902,  referring  to  232  craniotomies 
in  Chrobak's  Clinic  in  Vienna,  puts  the  mortality  at  7 "7  per  cent. 
Bretschneider,1  Zweifel's  Clinic,  Leipzig,  for  182  cases,  places  it  at 
7  per  cent.  But,  as  these  two  latter  operators  mention,  in  many 
cases  the  fatal  terminations  were  not  really  attributable  to  the 
operation.  Although  these  figures  show  a  high  maternal  death-rate, 
the  ultimate  results  are  even  worse,  for  the  morbidity  is  naturally 
very  great.     In   Chrobak's  Clinic,  for  instance,  according  to  Lierm- 

1  Arrhivf.  Gyn.,  Bd.  lxiii.,  Heft  1,  2,  p.  225. 


OPERATIONS  INVOLVING  DESTRUCTION   OF  CHILI)      183 

berger,  it  was  22  per  cent.,  and  in  the  Leipziger  Clinic  28  per  cent. ; 
in  my  sixty- three  cases  the  morbidity  was  fully  30  per  cent. 

Operation. — The  preparation  of  the  patient  for  this  operation 
must  be  most  thorough,  for  in  many  cases,  unfortunately,  the  operation 
is  had  recourse  to  only  after  many  vaginal  examinations  and  attempts 
at  delivering  with  forceps.  In  a  large  proportion  of  the  cases  sent 
into  the  Maternity  Hospital  the  cervix,  vagina,  and  perineum  are 
already  lacerated.  Sepsis  being  so  very  common  after  craniotomy 
(in  my  sixty-three  cases  the  mortality  was  12  per  cent,  and  the 
morbidity  30  per  cent.)  the  parts  about  the  vulva  and  vagina  must  be 
most  thoroughly  cleansed. 

The  first  step  in  the  operation  is  perforation.  This  is  carried  out 
by  the  perforator,  of  which  there  are  two  different  types — the  scissors 
form  and  the  trephine  form.  In  this  country  the  only  perforators 
now  employed  are  of  the  scissors  variety,  but  in  some  Continental 
clinics  the  trephine  is  still  occasionally  used.  The  advantages 
claimed  for  the  trephine  are  that  it  does  not  slip  so  easily  off  thefcetal 


Fig.  216. — Smellie's  Perforator. 

skull,  and  that  consequently  there  is  less  danger  to  the  soft  parts  of 
the  mother  ;  also  that  the  opening  made  allows  a  more  free  escape 
of  the  brain  contents.  It  is  questionable,  however,  if  these  slight 
advantages  compensate  for  the  inconvenience  of  the  instrument.  Be 
that  as  it  may,  the  instrument  is  now  hardly  ever  employed. 

The  earliest  form  of  scissors  perforator  was  devised  by  Levret. 
Smellie  (Fig.  216)  altered  the  instrument  slightly,  and  improved  it  by 
adding  a  shoulder  to  each  blade,  so  that  the  blades  might  be  prevented 
from  passing  completely  into  the  skull.  In  these  two  early  forms  of 
scissors  perforator  the  opening  in  the  skull  is  made  by  separating 
the  handles.  Obviously,  such  an  arrangement  in  time  was  found 
unsuitable,  and  the  more  modern  instrument,  by  which  the  opening 
is  made  by  compressing  the  separated  handles,  became  gradually 
perfected. 

There  are  many  different  forms  of  scissors  perforator,  but  the  two 
most  generally  employed  at  the  present  day  are  those  of  Naegele  and 
Simpson  (Fig.  217),  although  Oldham's  (Fig.  218)  is  quite  a  suitable 
instrument.     As    seen   in   the  illustrations,   the  perforator  has  two 


484 


OPERATIVE  MIDWIFERY 


cutting-blades,  each  being  Limited  by  a  shoulder.  The  handles,  when 
the  blades  are  in  apposition,  are  wide  apart,  and  held  firmly  there  by 
a  hinged  crossbar  lixed  to  the  ends  of  the  handles.  This  crossbar  is 
so  hinged  that  it  only  permits  of  separation  of  the  handles  when  the 
two  sides  of  the  bar  are  pulled  together. 

The  steps  in  perforating  are  as  follows:  The  handles  are  fixed  by 
means  of  the  crossbar.  The  instrument  is  then  grasped  in  the  right 
hand,  and  carried  into  the  vagina  protected  by  two  fingers  of  the  left 


Fig.  217. — Simpson's  Perforator. 

hand.  The  head  of  the  child,  if  it  is  not  sufficiently  fixed,  is  steadied 
by  an  assistant  grasping  the  head  from  the  outside.  Under  protection 
of  the  fingers  of  the  left  hand,  the  perforator  is  then  pushed  through 
the  skull  (Fig.  219).  The  situation  of  the  opening  made  in  the  skull 
will  be  considered  in  a  moment.  Sometimes  it  will  be  found  necessary 
to  move  the  perforator  from  side  to  side  so  as  to  bore  the  point  of  the 
instrument  through  the  bone.  In  pushing  or  boring  the  instrument 
through  the  skull,  the  direction  of  the  instrument  should  be,  as  far  as 


Fig.   218.—  Oldham's  Perforator. 


possible,  at  right  angles  to  the  surface  of  the  child's  head,  otherwise 
there  is  danger  of  the  instrument  glancing  off  the  skull  and  doing 
injury  to  the  soft  parts  of  the  mother.  And  here  I  may  remark  that 
it  is  of  the  greatest  importance  to  have  the  perforator  sharp ;  with  a 
sharp  perforator  there  is  almost  no  danger,  but  when  the  points  of 
the  instrument  are  blunt  a  greater  amount  of  force  is  required  to 
push  the  instrument  through,  and  naturally  there  is  greater  danger 
of  it  slipping.     In  most  cases  it  will  be  found  necessary,  in  order  to 


OPERATIONS  INVOLVING  DESTRUCTION  OF  CHILD      485 

get  the  perforator  at  right  angles  to  the  surface  of  the  skull,  to  depress 
the  handles  of  the  instrument  against  the  perineum.  The  blades  of 
the  instrument,  having  been  pushed  through  the  skull  as  far  as  the 
shoulders,  should  then  be  separated,  and  this  is  done  by  unlocking 
the  crossbar  and  pressing  the  handles  together  (Fig.  220).  A  large 
tear  in  the  skull  having  now  been  made  in  one  direction,  the  instru- 
ment should    be    turned   round   and   a    similar   tear  made  at  right 


Fig.  219. — The  Perforator,  having  been  carried  up  the  Vagina  under  Protection  of 
the  Fingers  of  the  Operator's  Left  Hand,  is  being  pushed  into  the  Skull  iu  the 
Neighbourhood  of  the  Anterior  Fontanelle. 

angles.  The  handles  are  again  fixed  by  the  crossbar.  This  having 
been  done,  the  points  of  the  instrument  should  be  pushed  into  the 
skull  and  the  brain  broken  up  in  all  directions.  The  instrument  is 
now  withdrawn  under  protection  of  the  left  hand. 

I  have  referred  to  the  danger  of  the  perforator  slipping,  a  danger 
which  is  practically  nil  if  the  instrument  is  sharp  and  the  operator  is 


486  OPERATIVE  M1DWI  l'Kl;V 

at  all  careful.  There  is  another  danger  which  it  seems  almost  un- 
necessary to  mention  did  I  not  know  that  once  or  twice  it  has  heen 
made  ;  it  is  mistaking  the  projecting  promontory  for  the  foetal  skull. 
Such  an  unfortunate  mistake  cannot  occur  unless  the  operator  18 
careless  or  excited. 

An    important  matter  is  the  situation  of   the  opening  made    in 


Fid.  220.  —Tin'  Blades  are  being  separated  }<y  pressing  together  the  Handles. 

the  skull.  Naturally,  if  the  perforator  is  simply  pushed  through  the 
presenting  part,  the  situation  of  the  opening  will  depend  upon  the 
presentation.  In  the  vertex  it  will  be  situated  somewhere  towards 
the  anterior  or  posterior  fontanelles,  in  the  brow  through  the  frontal 


OPEKATIONS  INVOLVING  DESTRUCTION  OF  CHILD      487 

bones,  in  the  face  through  an  orbit  or  through  the  mouth  (Fig.  221). 
In  the  after-coming  head  it  will  be  in  the  neighbourhood  of  the 
posterolateral  fontanelle.     Now,  all  these  points  are  the  situations 


Fig.  221.— Perforation  and  Application  of  the  Three-bladed  Cephalotribe 
through  the  Mouth  in  a  Case  of  Face  Presentation. 

most  easily  reached  in  the  particular  presentations ;  and  as  regards 
the  brow,  face,  and  after-coming  head,  they  are  the  best  situations. 
In  the  various  vertex  presentations,  however,  it  is  somewhat  different; 
with  them  it  is  often  of  advantage  to  have  the  opening  in  the  skull  as 


188  OPERATIVE  MIDWIFERY 

Dear  the  anterior  fontanelle  ae  possible-  The  reason  for  this  is  that 
with  the  modern  instrument  employed  for  extracting  the  head  it  ia 
of  great  importance  to  gel  one  blade  well  down  over  the  face  of  the 
child.     Let  lie  consider  a  few  examples. 

I.i  the  ordinary  flat   pelvfr    the  head  engages  in  the  transvi 
diameter  of  the  pelvis   with  the  anterior  and   posterior   fontanellea 


Fig.  222. — Showing  Ideal  Grasp  of  Head  with  the  Three-bladed  Cephalotribe :  One 
Blade  well  down  over  Face,  and  the  Other  over  Occiput. 

about  the  same  level.  In  the  simple  cases  where  the  sagittal  suture 
is  equidistant  from  the  promontory  and  symphysis,  the  hole  can 
readily  be  made  in  the  middle  line,  through  or  near  the  anterior 
fontanelle,  and  the  blades  of  the  extracting  instrument  can  be  applied 
over  the  face  and  occiput  |  Fig.  222).  When,  however,  the  sagittal  suture 
is  placed  nearer  the  promontory  or  the  symphysis,  and  an  anterior 
or  posterior  'parietal  presentation'  exists,  the  opening  in  the  head 


OPERATIONS  INVOLVING  DESTRUCTION  OF  CHILD      489 

will  come  to  be  through  the  presenting  parietal  bone,  and  the  extract- 
ing instruments,  when  applied,  will  tend  to  grasp  the  head  to  one 
or  other  side  of  the  middle  line.     We  have  seen,  when  considering 


Fig.  223. — Showing  the  Effect  of  crushing  only  One-half  of  the  Head  in  Cases 
of  Posterior  Parietal  Presentation. 

forceps  extraction,  that  an  anterior  parietal  preservation  is  very  much 
more  favourable  than  a  posterior,  and  that  the  child  can  be  much 
more  easily  extracted.     The    same   applies   also  to  extraction  after 


490  OPERATIVE  MIDWIFERY 

perforation,  for  even  although  the  grasp  of  the  head  is  not  exactly  in 
the  middle  line  with  an  anterior  pariotal  presentation,  it  is  sufficient 
for  extraction;  whereas  with  the  posterior  parietal  presentation  the 
instrument,  not  having  a  sufficient  hold  for  the  increased  traction 
necessary,  slips,  and  only  one-half  of  the  head  is  properly  crushed 
(Fig.  223).     As  I  have  already  stated,  the  posterior  parietal  presenta- 


FlG.   224. — Showing  the  Perforation  through  Posterior  Fontanelle  in  Case  of  Extreme 

Flexion  of  the  Head. 

It  will  be  observed  that  the  blade  placed  over  the  face  does  not  reach  farther  than  the  forehead. 

tion  is  very  much  more  frequent  than  the  anterior  in  cases  of  extreme 
pelvic  deformity. 

The  most  difficult  cases  of  all  are  those  in  which  the  maternal 
pelvis  is  generally  contracted.  In  these  cases,  it  will  be  remembered, 
(Fig.  224),  the  head  becomes  extremely  flexed,  and  the  presenting  part 
is  somewhere  in  the  neighbourhood  of   the  posterior  fontanelle,  so 


OPERATIONS  INVOLVING  DESTRUCTION  OF  CHILD     491 

that,  if  the  presenting  part  is  perforated,  the  blades  of  the  cephalo- 
tribe,  which  should  reach  over  the  face,  cannot  be  placed  over  the 
face  farther  than  the  child's  forehead  (Fig.  224),  and  the  head,  when 
traction  is  made  on  the  instrument,  slips  from  it  (Fig.  225).  The 
advantage  of  perforating  as  near  the  anterior  fontanelle  as  possible 
was  fully  appreciated  by  the  older  writers  when  the  cranioclast  was 
in  use,  and  several  of  them  recommended  what  I  have  frequently 
found  advantageous,  the  making  of  a  second  opening  in  the  skull.     I 


Fig.  225. — Showing  the  Cranioclast  slipping  because  the  Anterior  Blade  is  not 
applied  far  enough  down  over  the  Face. 

do  this  as  follows :  Having  inserted  the  middle  blade  and  applied  the 
outer  one  over  the  occiput,  I  push  the  occipital  end  of  the  head 
upwards  until  I  bring  the  anterior  fontanelle  within  reach.  I  then 
make  a  second  puncture  in  that  region. 

I  have  already  said  that  after  perforation  the  perforator  should  be 
pushed  into  the  skull  and  the  brain  substance  thoroughly  broken  up. 
This  having  been  done,  the  skull  may  be  washed  out  with  a  double- 


492  OTKIJATIVK  MIDW1FKM 


I 


channelled  uterine  douche  tube  (Bozeman).    One  can  never  wash  awn 
all  the  brain  material  by  this  means,  but  one  can  certainly  get  rid  of 
a  good  deal. 

Extraction  of  the  Head. — At  different  times  it  has  been  the. 
custom  to  leave  the  perforated  head  to  be  expelled  by  the  unaided 
forces.  This  has  been  entirely  abandoned,  and  very  rightly,  for  we 
now  have  suitable  instruments  for  extracting  it. 

In  the  slighter  degrees  of  pelvic  deformity  the  ordinary  obstetric 
forceps  is  sometimes  quite  sufficient,  and  I  have  several  times 
employed  it ;  but  when  the  pelvic  dimensions  are  small,  and  the 
bulk  of  the  head  has  to  be  diminished,  the  obstetric  forceps  fail  to 
retain  a  sufficient  grasp  of  the  perforated  head. 

The  earliest  instruments  for  extracting  the  perforated  head  con- 
sisted of  hooks  and  simple  forms  of  toothed  forceps.  The  hook  in  its 
perfected  form  is  known  as  the  crotchet  (Fig.  226).  At  one  time  it 
was  very  extensively  used,  and,  indeed,  is  even  yet  employed  by  some 
of  the  older  accoucheurs.  It  is  passed  into  the  skull,  and  the  point 
is  made  to  catch  on  some  bony  ridge.     Two  fingers  are  then  applied 


3) 


Fig.   226. — Blunt  Hook  and  Crochet. 


outside  of  the  skull  opposite  the  point  of  the  instrument,  and  traction 
is  made  on  the  head.  Naturally,  one  can  exert  very  little  traction 
upon  the  fore-coming  head  by  such  a  manoeuvre ;  even  when  one  can 
fix  the  crotchet  into  the  orbit  or  mouth  it  is  apt  to  tear  through  the 
soft  bones.  For  extracting  the  after-coming  head,  however,  it  is  very 
serviceable,  as  we  shall  see.  Modern  operators,  in  consequence,  have 
almost  abandoned  the  crotchet,  except  in  extracting  the  after-coming 
head.  Similarly,  the  procedure  of  turning  after  craniotomy  has  been 
given  up  because  of  the  great  danger  of  lacerating  the  uterus.  We 
now  trust  entirely  to  the  perfected  forms  of  cephalotribe. 

The  first  great  improvement  in  the  older  bone  forceps  was  the 
instrument  that  is  known  as  the  cranioclast  (Fig.  227),  various  forms 
of  which  were  devised  by  Simpson,  Barnes,  Braun,  and  more  recently 
by  Peters.  This  instrument,  which  consists  of  two  blades,  was 
extensively  employed  last  century,  and  has  only  been  recently  dis- 
placed by  the  three-pronged  instrument  of  Auvard,  Winter,  Zweifel, 
Duhrssen,  and  others.  The  cranioclast,  as  I  said,  consists  of  two 
blades,  one  of  which  is  pushed  in  through  the  opening  in  the  skull,  and 


OPERATIONS  INVOLVING  DESTRUCTION  OF  CHILD     498 

the  other  which  is  applied  to  the  outside,  preferably  over  the  face.  In 
the  cranioclast  the  two  blades  can  be  forcibly  brought  together  by  a 
strong  screw  at  the  end  of  the  handles.  The  instrument,  without 
doubt,  was  a  great  improvement  on  the  older  forms  of  bone  forceps, 
which  were  only  of  use  for  pulling  away  portions  of  the  skull ; 
but  it  frequently  slipped,  especially  if  the  external  blade 
was  not  applied  well  over  the  face.  In  many  clinics, 
therefore,  it  has  been  entirely  abandoned,  and  for  the  last 
twelve  years  we  have  never  employed  it  in  the  Glasgow 


Fig.  227. — Braun's  Cranioclast. 

Maternity  Hospital.  The  proportion  of  cases  in  which  the  cranioclast 
failed,  and  the  head  had  to  be  broken  up  and  removed  piecemeal,  is 
variously  stated,  but  it  may  be  estimated  at  about  12  to  16  per  cent. 

Older,  however,  than  the  perfected  bone  forceps  or  cranioclast  is 
the  instrument  known  as  the  cephalotribe,  which  was  first  introduced 
by  Baudelocque.     Baudelocque's  instrument  was  most  cumbrous  and 


Fig.  228. — Simpson's  Basilyst. 


unwieldy.  It  was  immensely  improved  (Fig.  229)  by  Eduard  Martin, 
Tarnier,  and  in  this  country  by  Simpson  and  Braxton  Hicks.  The 
cephalotribe  also  consists  of  two  blades,  but  with  this  difference,  that 
both  were  designed  for  external  application  very  much  in  the  same 
manner  as  forceps.  By  means  of  a  screw  at  the  end  of  the  handles 
the  blades  are  brought  together  and  the  head  very  completely  crushed. 
In  many  respects  the  cephalotribe  is  a  more  useful  instrument  than 


l'.ll 


OPERATIVE  MlDWTEEIlY 


the  cranioclast ;  it,  however,  possesses  this  great  disadvantage,  that 
the  head  frequently  Blips  from  between  the  blades. 

For  breaking  up  the  base  of  the  skull  various  instruments  have 
been  devised.     They  are  termed  basilysts  (Eig.  228). 

The  modern  instrument,  which  is  in  some  respects  a  much  more 
complicated  one,  is  a  combination  of  the  cranioclast  and  cephalotribe. 
As  can  be  seen  from  the  illustrations  (Figs.  223,  224,  230),  it  consists  of 
three  blades,  one  of  which  is  placed  within  the  skull  through  the  opening 
made  by  the  perforator,  while  the  other  two  are  applied  externally. 
Long  before  Tarnier  introduced  his  instrument  three-bladed  cranio- 
elasts  had  been  devised  by  Valette,  Huter,  and  others,  but  little 
attention  was  given  to  them  ;  indeed,  even  Tarnier's  instrument  was 
not  fully  appreciated  until  Auvard  modified  it.  Since  Auvard  altered 
the  instrument,  and  brought  it  prominently  before  the  profession, 
several  slight  modifications  of  it  have  been  made  by  Winter,  Diihrssen, 
Yeit,  and,  last  of  all,  by  Zweifel. 


Fig.  229. — Simpson's  Ce]>h;ilotribe. 

In  the  Maternity  Hospital  we  employ  Auvard's  instrument,  in 
which  the  blades  and  shanks  are  of  more  than  usual  length.  This 
lengthening  of  the  blades  is  in  order  to  avoid  having  the  lock  in  the 
vagina.  We  have  found  it  a  most  useful  instrument.  It  has  simplified 
the  operation  of  craniotomy  immensely,  for  in  place  of  taking  an  hour 
or  two,  as  was  the  case  with  the  crotchet  and  the  bone  forceps, 
it  seldom  takes  more  than  one-third  or  one- fourth  of  that  time.  I 
■cannot  speak  too  highly  of  the  three-bladed  instrument. 

In  the  three-bladed  instrument  one  blade  is  passed  through  the 
•opening  in  the  skull,  and  the  other  two  are  applied  over  the  external 
•surface  of  the  head.  They  are  brought  together  by  a  strong  screw, 
and  when  approximated  and  the  head  crushed,  are  kept  in  their  place 
hy  the  two  shoulders,  which  are  pulled  down  into  position,  and  serve 
-as  a  means  of  exerting  traction.  The  instrument  is  straight ;  it  has 
no  pelvic  curve.     It  is  employed  as  follows  : 

The  opening  having  been  made  with  a  perforator,  the  middle 
Wade  is  pushed  through  the  opening  up  to  the  base  of   the  skull. 


OPERATIONS  INVOLVING  DESTRUCTION  OF  CHILD     495 

This  middle  blade  is  not  employed  as  a  perforator.  In  some  instru- 
ments the  middle  blade  is  screwed  into  the  base  of  the  skull — 
preferably  into  the  foramen  magnum.  This  is  not  altogether  free 
from  risk,  unless  the  hand  is  passed  into  the  uterus  and  applied  to 
the  base  of  the  skull,  so  as  to  ensure  that  the  point  of  the  instrument 
is  actually  being  bored  into  the  base. 

Having  passed  the  point  of  the  instrument  well  up  to  the  base  of 
the  skull,  one  of  the  external  blades  is  now  applied.  It  will  be  found 
best,  when  at  all  possible,  that  the  first  external  blade  should  be 
applied  over  the  surface  of  the  face.  If  the  occiput  is  first  grasped  by 
the  external  blade,  and  the  screw  applied,  there  will  result  an  increase 
of  flexion  (unless  the  head  is  perforated  very  far  forwards),  and  the 
second  blade,  which  is  to  be  passed  over  the  face,  will  not  extend  far 
enough  down  over  that  part.  The  blade  is  placed  in  position  by  first 
carrying  it  upwards,  under  protection  of  the  left  hand,  to  the  side 
of  the  promontory,  and  rotating  it  into  position,  as  one  does  with 
forceps.  While  this  is  being  done,  it  is  of  great  service  if  an  assistant 
steadies  the  head  externally  and  keeps  it  extended,  for  seldom 
does  the  inner  blade  hold  it  sufficiently  firmly  in  position.  The 
handle  of  the  instrument  should  be  pushed  well  backwards  against 
the  perineum,  so  that  the  blade  will  be  brought  as  far  forwards  as 
possible.  The  external  blade  being  brought  into  position  over  the 
face,  the  screw  is  now  turned,  and  the  front  part  of  the  head  crushed. 
One  can  always  tell  at  this  stage  that  a  good  grasp  of  the  head  has 
been  obtained  when  there  is  considerable  resistance  to  approximating 
the  blades.  If  they  are  easily  brought  together  with  the  screw,  one 
can  be  perfectly  certain  the  grasp  is  defective.  It  will  be  found  very 
undesirable  to  apply  the  other  blade,  and  attempt  to  crush  the  head, 
when  the  grasp  of  the  instrument  is  unsatisfactory,  for  once  the  head 
has  been  crushed  in  a  wrong  direction,  it  is  not  easy  to  apply  the 
instrument  in  a  proper  direction,  as  the  blades  always  tend  to  slip 
into  the  first  position.  The  other  external  blade  is  now  introduced 
from  the  opposite  side  of  the  pelvis,  usually  in  the  neighbourhood  of 
the  sacro-iliac  synchondrosis,  and  rotated  into  its  proper  position  over 
the  occiput.  In  doing  this  it  is  sometimes  easier  to  place  the  third 
blade  into  its  proper  position,  and  at  other  times  to  keep  the  third 
blade  fixed,  and  rotate  the  occiput  on  to  it  with  the  other  two  blades. 
The  third  blade  is  now  locked,  the  screw  applied  (Fig.  230),  and  the 
head  again  crushed.  The  position  of  the  blades  and  the  appearance 
of  the  crushed  skull  are,  as  in  the  illustration,  already  given  (Fig.  222), 
and  if  this  ideal  grasp  is  obtained  I  have  never  seen  this  instrument 
slip  during  the  process  of  extraction. 

The  instrument  having  been  applied  as  described,  the  operator 


496 


OPERATIVE  MIDWIFERY 


now  proceeds  to  extract,  the  crashed  head.  In  doing  thin  the  blades 
Bhould  be  encouraged  to  rotate  into  the  smallest  diameter,  which,  in 
the  deformed  pelvis  most  commonly  encountered,  is  the  antero- 
posterior. Usually,  by  Bimply  pulling  upon  the  head,  the  instrument 
will  rotate  spontaneously,  sometimes  towards  one  side,  sometimes  to 


Fig.  230. — The  Blade  applied  over  the  Fair  has  been  fixed,  and  the  Other  Blade  p] 
over  the  Occiput  is  being  screwed  np  so  that  the  Head  is  completely  crushed. 

the  other;  but  if  it  does  not  do  so,  the  operator  may  carefully  en- 
courage rotation.  Very  frequently  one  sees  the  beginner  forgetting 
this,  with  the  result  that  the  crushed  head  catches  on  the  brim. 
He  must  remember,  also,  to  direct  his  traction  well  back.  In  the 
ordinary  rachitic  pelvis,  once  the  head  has  passed  the  brim,  the 
further  extraction  of  the  child  is  easy  ;  but  in  other  deformities  of  the 


OPERATIONS  INVOLVING  DESTRUCTION  OF  CHILD    497 

pelvis,  where  the  whole  cavity  is  contracted,  as  in  extreme  degrees  of 
general  contraction,  or  where  the  outlet  is  narrowed,  as  in  kyphotic 
pelvis,  there  may  be  difficulties  down  through  the  whole  pelvis,  and 
even  at  the  outlet.  By  steady  traction,  directed  as  far  back  as 
possible,  the  head  is  slowly  pulled  down  through  the  pelvis. 

As  a  rule,  unless  the  deformity  is  extreme,  a  slight  amount  of 
force  is  sufficient  to  accomplish  the  delivery  of  the  head.  When, 
however,  the  deformity  is  great,  or  when  the  grasp  of  the  head  is 
not  satisfactory,  a  more  than  usual  amount  of  force  is  required.  In 
these  latter  cases  the  danger  of  the  instrument  slipping  is  greatly 
increased.  The  operator  should  therefore  watch  carefully  for  this, 
and  during  traction  should  keep  the  fingers  of  the  left  hand  against 
the  head,  and  make  sure  that,  while  he  is  pulling,  the  head  is 
descending  along  with  the  instrument.  These  fingers  in  the  vagina, 
which  inform  him  as  to  how  the  head  is  descending,  serve  the  other 
purpose  of  protecting  any  splinters  of  bone  from  injuring  the  soft 
parts.  With  the  modern  instrument,  this  danger  of  laceration  of 
the  soft  parts  by  splinters  is  reduced  to  a  minimum,  for  the  scalp 
being  still  intact,  except  for  the  perforation  hole,  prevents  the  broken 
bones  from  doing  any  injury. 

Having  extracted  the  head,  the  trunk  is  removed  without  difficulty. 
Sometimes  the  shoulders  give  trouble  when  the  child  is  of  unusual  size. 
In  such  cases  the  division  of  the  clavicles  is  necessary  to  facilitate 
extraction.  This  operation,  termed  cleidotomy,  will  be  referred  to  later. 
After  the  shoulders  are  born,  the  rest  of  the  trunk  is  easily  delivered. 

I  have  never  required  to  employ  the  cranioclast  or  cephalotribe  in 
breech  presentations ;  but  if  it  should  be  necessary,  the  middle  blade 
should  be  passed  into  the  rectum,  and  the  two  others  over  the  pelvic 
walls  of  the  foetus. 

Craniotomy  on  the  After-coming1  Head.— As  the  operation  of 
craniotomy  upon  the  after-coming  head  differs  considerably  from  the 
operation  upon  the  fore-coming  head,  it  is  necessary  that  we  consider 
its  details.  In  some  circumstances  it  is  easier ;  in  others  it  is  more 
difficult.  Provided  the  pelvis  is  not  too  deformed,  the  operation  can 
readily  be  performed,  and  the  extraction  is  easier  ;  but  in  extreme 
degrees  of  deformity  it  is  more  difficult,  as  the  head  is  far  out  of 
reach,  the  brain  substance  does  not  readily  escape,  and  the  cephalo- 
tribe is  difficult  of  application. 

Some  years  ago  Donald  published  a  very  interesting  paper,1  in 
which  he  pointed  out  the  advantages  of  craniotomy  on  the  after- 
coming  head,  and  in  which  he  recommended,  when  craniotomy  was 
decided  upon,  and  the  child  could  still  be  easily  turned,  that  version 

1  Lond.  Obst.  Trans.,  vol.  xxxi.,  p.  28. 

32 


198 


Ol'EKATIVK  Mll'WII  KltY 


should  be  first  performed.     His  paper  was  freely  discussed,  but  the 
majority  of  those  who  spoke  were  rather  sceptical  of  the  advanta 
claimed  by  bhe  author. 

The  operation  is  carried  out  as  follows:  The  arms  of  the  child 
having  been  brought  down,  the  assistant  grasps  the  feet,  and  directs 


Pig.  231.  — Perforating  the  After-coming  Head  through  the  Postero-lateral  Fontanelle. 


traction  upon  them,  in  the  direction  desired  by  the  operator.  The 
operator  carries  the  perforator,  protected  by  the  two  fingers  of  the 
left  hand,  along  the  dorsal  aspect  of  the  trunk,  until  he  reaches  the 
skull.  He  then  pushes  the  instrument  through  the  skull,  in  the 
neighbourhood  of  the  postero-lateral  fontanelle  (Fig.  281).  Some- 
times this  point   is   difficult   to   reach,   and   he   can   only  perforate 


OPEEATIONS  INVOLVING  DESTRUCTION  OF  CHILD    499 

through  the  occipital  bone  in  the  middle  line.  In  these  cases  he 
must  make  sure  that  he  really  perforates  the  skull,  and  not  the 
uppermost  part  of  the  vertebral  column ;  for  if  this  mistake  is  made 
not  only  will  he  find  it  difficult  to  gain  entrance  to  the  skull,  but, 
having  fractured  the  vertebral  column,  he  will  have  rendered  extrac- 
tion of  the  head  more  difficult. 


Fig.  232. — Extracting  the  After-coming  Head  with  the  Crotchet. 


The  perforator  is  pushed  through  the  skull,  and  an  opening  made 
in  the  manner  already  described  for  perforation  of  the  fore-coming 
head. 

The  brain  matter  having  been  broken  up  and  washed  out,  extrac- 
tion is  now  proceeded  with.  It  will  be  found  in  many  cases  this  can 
readily  be  accomplished  with  the  crotchet,  the  point  of  which  should 
be  turned  towards  the  vertebral  column.      With  this  instrument  a 


500  OPERATIVE   MII'WIIKIIY 

very  firm  hold  of  the  skull  can  he  obtained,  seeing  that  the  hones  at 
the  base  of  the  skull  are  so  strong.  The  illustration  (Fig.  232)  shows 
the  manner  in  which  the  operator  protects  the  soft  parts  of  bhe  mother 
with  his  lingers,  while  he  exerts  traction  with  1 1 1 « -  crotchet.  The 
traction  should  he  steady  and  gradual,  so  as  to  permit  of  the  hones 
of  the  cranial  vault  collapsing.  If  with  moderate  traction  the  head 
does  not  collapse,  it  is  not  safe  to  exert  an  undue  amount  of  force,  for 
the  hody  may  he  dragged  from  the  head  and  the  latter  left  in  the 
uterus.  Should  one  fail  to  deliver  with  the  crotchet,  the  cephalotrihe 
must  he  employed.  This,  however,  is  sometimes  difficult,  especially 
if  there  is  general  deformity  of  the  pelvis,  for  there  is  so  little  room 
for  the  instrument  and  the  neck  of  the  child  in  a  deformed  pelvic 
canal. 

It  is  claimed  hy  some  that  the  roof  of  the  mouth  is  a  hetter 
site  for  perforating  the  skull,  as  the  brain  suhstance  escapes  morel 
freely  through  such  an  opening.  It  is,  however,  difficult  to  reach! 
that  part  in  some  cases,  and  the  hold  one  obtains  with  the  crotchet 
is  very  feeble,  as  the  bones  are  so  soft.  Occasionally  it  might  be  a 
quite  useful  procedure  to  make  two  perforations,  one  through  the 
occipital  bone  and  the  other  through  the  palate. 

Decapitation. 

The  operation  of  decapitation  consists  in  the  severing  of  the 
head  from  the  trunk,  followed  by  the  extraction  of  the  trunk  and  then 
of  the  head.  It  is  an  operation  of  considerable  antiquity,  for  we  find 
it  recommended  by  Celsus. 

The  operation  has  always  been  looked  upon  as  one  of  great 
difficulty.  I  cannot  say  that  it  is  easily  carried  out,  but  in  most 
cases  it  may  be  performed  without  much  difficulty,  and  my  colleagues 
and  I  in  the  Maternity  Hospital  prefer  this  operation  to  the  much 
slower  one  of  evisceration.  Personally  I  have  only  once  found  the 
operation  impossible,  and  that  was  in  the  case  of  an  impacted  trans- 
verse presentation  with  a  contracted  pelvis,  where  the  child's  arm 
was  prolapsed,  and  owing  to  the  size  of  the  child  the  neck  could 
not  be  reached.  I  therefore  perforated  the  chest,  divided  the  trunk, 
extracted  the  lower  part  of  the  trunk,  removed  the  arms,  and  finally 
extracted  the  head  after  perforating  it  (evisceration,  spondylotomy, 
and  craniotomy). 

I  find  decapitation  is  very  seldom  performed  by  practitioner^  in 
this  country.  This  is  most  unfortunate,  for  there  are  a  number  of 
cases  in  which  it  is  the  only  safe  treatment.  There  have  been  in 
recent  years  a  considerable  number  of  patients  sent  into  the  hospital  in 


OPERATIONS  INVOLVING  DESTRUCTION  OF  CHILD     501 

which  practitioners  have  made  fruitless  attempts  at  version,  and  where 
with  very  little  difficulty  we  have  decapitated  and  terminated  the 
labour. 

The  indication  for  the  operation  is  an  impacted  transverse  pre- 
sentation, where  the  uterus  is  grasping  the  child  so  firmly  that  version 
is  dangerous.  It  is  not  a  little  difficult  to  decide  when  one  should 
desist  from  making  attempts  at  version,  for  even  when  the  waters  have 


1PK 


Fiu.  233. — Decapitating  Hook  (Ramsbotham's). 

drained  away,  and  the  uterus  is  closely  applied  to  the  surface  of 
the  child,  by  deeply  anaesthetizing  the  patient  the  uterus  relaxes 
to  a  surprising  extent,  and  version  is  sometimes  more  easily  per- 
formed than  one  expected.  It  is  my  custom,  therefore,  before 
proceeding  to  decapitation,  to  try  and  estimate  the  relative  danger 
of  performing  version.  I  decide  to  desist  from  version  and 
have    recourse    to    decapitation    in    all   cases   if   the   child   is   dead 


Fig.  234. — Decapitating  Hook  (Jardine's). 

or  dying  (judged  by  the  pulsations  of  the  umbilical  cord) ;  and, 
if  it  is  living,  where  the  lower  uterine  segment  is  very  much  thinned 
out,  the  head  is  below  the  retraction  ring,  and  the  uterus  still 
grasps  the  child  even  although  the  patient  is  deeply  anaesthetized. 
The  reason  why  I  apparently  sacrifice  the  child  in  these  latter  cases 
is  because,  if  a  transverse  presentation  has  become  impacted,  the 
prospect  of  the  child  surviving  a  difficult  version  and  extraction  is 
so  small  as  to  be  almost  negligible.  This  matter  is  considered  in 
Chapters  VI.  and  XXII. 


502 


ol'HRATIVE  MIDWIFERY 


The  severing  ol  the  head  of  the  child  from  the  trunk  may  be 
carried  out  with  a  variety  of  instruments;  it  has  been  done  with 
cord,  wire,  chains,  ecraseurs,  and  scissors,  but  the  two  more  common 
instruments  employed  are  the  decapitating  knife,  of  which  the  best- 
known  form  is  that  of  Ramsbotham  (Fig.  233),  and  the  hook  devised 
by  Braun.  In  recent  years  both  of  these  have  been  much  modified  ; 
Sclmltze  and  Jardine  have  modified  the  former,  Zweifel  and  others 
have  modified  the  latter.  The  objection  to  Ramsbotham's  knife  is 
that  it  is  too  large,  and  is  often  difficult  to  manipulate ;  and  the 
objection  to  Braun's  hook  is  that  owing  to  narrowness  of  the  curve  it 
is  not  always  easy  to  get  it  over  the  child's  neck.  Besides,  the  method 
of  twisting  the  head  off  with  a  hook  is  crude  as  compared  to  dividing 


Fig.  235. — Showing  the  Manner  in  which  the  Decapitating  Hook  or  Knife  is  employed. 


the  neck  with  a  knife.  Schultze's  knife  is  a  distinct  improvement  on 
Ramsbotham's,  but,  I  think,  even  better  than  the  latter  is  the  com- 
bined hook  and  knife  of  Jardine  (Fig.  234). 

The  operation  of  decapitation  is  carried  out  as  follows  : 
The  exact  position  of  the  neck  having  been  determined,  the 
decapitating  instrument,  protected  by  the  palm  of  the  left  hand,  is 
passed  up  over  the  child's  shoulder  (Fig.  235).  The  point  is  then 
turned  over  the  neck.  Generally  the  neck  can  be  reached  most  easily 
from  the  front,  as  seen  in  the  illustration,  but  occasionally  it  will  be 
found  easier  to  pass  the  hook  round  from  behind. 

In  a  great  number  of  cases  the  arm  is  prolapsed,  and  this  is  usually 
an  advantage,  unless  the  arm  and  shoulders  of  the  child  are  unusually 


OPERATIONS  INVOLVING  DESTRUCTION  OF  CHILD      503 

large,  for  by  traction  on  the  arm  the  neck  can  be  brought  more 
readily  within  reach  (Fig.  236).  If  the  knife  is  used,  by  a  backward 
and  forward  movement  it  is  carried  through  the  neck,  but  if  Braun's 
hook  is  the  instrument  employed,  then  it  is  twisted  round  and  round 
until  the  neck  is  completely  severed,  the  head  being  steadied  from  the 
outside.     By  this  latter  method,  which  I  have  indicated  is  very  crude, 


Fig.  236. — The  Assistant  pulls  upon  the  Prolapsed  Arm  so  as  to  steady  the  Fcetus  and 
bring  its  Neck  within  reach.  The  Operator  then  passes  the  Decapitating  Hook  over 
the  Neck  under  Protection  of  his  Left  Hand.     He  is  here  dividing  the  Neck. 


the  bones  of  the  spinal  column  are  shattered.     There  is  then  only  a 
band  of  skin  to  be  divided  with  scissors. 

After  the  head  is  completely  severed,  the  trunk  is  removed  by 
making  traction  on  the  prolapsed  arm.  There  now  remains  the 
removal  of  the  severed  head,  and  this  is  easily  accomplished  manually 
or  with  forceps,  unless  the  pelvis  is  deformed.  Should  the  pelvis  be 
contracted,  the  head  is  steadied  by  suprapubic  pressure,  perforated, 


504 


OPERATIVE   MIDWIFKIIY 


and  then  removed  with  the  cranioclast,  crotchet,  etc.  (Fig.  237  . 
Care  must  he  taken  in  extracting  the  head  that  the  ragged  neck  does 
not  injure  the  soft  parts,  for  usually,  when  the  head  is  severed,  the 
greater  part  of  the  neck  is  left  attached  to  the  head,  the  line  of 
cleavage  heing  close  to  the  shoulders. 

The  operation  of  decapitation  has  heen  attended  with  excellent 


Fig.  237. — Removing  the  Detached  Head  with  the  Crotchet. 

results  in  the  Maternity  Hospital.  Since  1901  inclusive  it  was  per- 
formed twenty-five  times  without  any  maternal  deaths,  although  in 
all  cases  the  women  were  very  ill  when  brought  into  the  hospital. 


Evisceration. 

The  operation  of  evisceration  consists  in  the  removal  of  the 
abdominal  and  thoracic  contents,  with  the  object  of  diminishing  the 
bulk  of  the  child,  and  so  permitting  of  its  being  extracted. 

The  most  common  indication  is  an  impacted  shoulder  presentation 


OPERATIONS  INVOLVING  DESTRUCTION  OF  CHILD      505 

in  which  decapitation  is  impossible  owing  to  the  neck  being  out  of 
reach.  The  operation  is  also  occasionally  necessary  in  monsters,  and 
where  the  abdomen  or  thorax  of  the  child  is  distended  with  fluid  or 
new  growths. 

The  operation  is  performed  by  first  making  a  large  opening  with  a 
perforator  into  the  abdomen  or  thorax  ;  the  viscera  are  then  broken 
up  and  removed  manually.  During  these  manipulations,  if  the  pre- 
sentation is  transverse,  the  trunk  of  the  child  may  be  steadied  by 
means  of  the  prolapsed  arm.  As  the  abdominal  contents  are  the  most 
bulky,  the  removal  of  them  diminishes  most  the  bulk  of  the  child. 
Where  the  opening  is  made  into  the  thorax,  the  abdominal  contents 
can  be  reached  through  the  diaphragm. 

After  evisceration  the  child  can  often  be  extracted  in  a  doubled-up 
condition,  provided  the  pelvis  is  of  normal  size  and  the  child  is  small 
or  macerated  ;  but  where  the  pelvis  is  deformed,  or  the  foetus  large, 
the  vertebral  column  has  to  be  divided.  The  term  '  spondylotomy  * 
was  given  by  Simpson1  to  this  division  of  the  vertebral  column. 
It  can  be  done  best  with  scissors,  but  it  is  often  a  very  tedious 
operation. 

In  cases  where  the  presentation  is  transverse,  and  the  trunk  has 
been  divided,  the  lower  part  of  the  trunk  is  first  extracted  by  making 
traction  on  the  legs.  The  extraction  of  the  other  half  of  the  child 
must  be  carried  out  with  great  care  if  there  is  much  of  the  trunk  left, 
because  when  pulling  upon  the  trunk  the  ragged  edges  of  bone  may 
injure  the  parturient  canal. 

In  the  simpler  cases  where  the  child  has  to  be  eviscerated  on 
account  of  the  bulk  of  its  abdominal  or  thoracic  contents,  the  opera- 
tion is  more  simple.  The  abdomen,  if  the  presentation  is  a  breech, 
can  be  easily  reached  when  the  legs  are  brought  down.  In  head  pre- 
sentations there  may  be  a  little  more  difficulty,  for  the  abdomen  may 
sometimes  require  to  be  opened  through  the  diaphragm,  although  in 
all  cases  in  which  I  have  required  to  perform  the  operation  I  have 
been  able  to  perforate  the  abdomen  direct. 


Cleidotomy. 

The  operation  of  cleidotomy,  or  division  of  the  clavicles,  has  for 
its  object  the  reducing  of  the  bulk  of  the  shoulder  girdle.  In  all 
probability  the  operation  was  performed  in  times  past,  but  attention 
was  first  directly  drawn  to  the  advantages  of  the  operation  by  Spencer, 
in  a  paper  entitled,  '  On  Delivery  of  Certain  Cases  of  Impaction  of  the 

1  '  Obstetric  Works,'  vol.  i.,  p.  502. 


50(5 


OPERATIVE  Mim\IFEl;Y 


Trunk  of  the  Foetus.'1  Pie  says:  '  It  may  be  necessary  to  reduce  the 
width  of  the  child's  shoulder.  With  this  object  I  have  found  it  a 
useful  plan  to  snip  through  the  clavicles  with  scissors.'     A  few  weeks 


Fig.  238. — Showing  the  Collapsed  Shoulder  (Jirdle  after  Cleidotomy. 
The  child  was  a  very  large  one,  and  had  to  be  extracted  with  the  cephalotrilu-. 

later  Phenomenon0 2  made  a  contribution  under  the  title,  '  Zur  Frage 
iiber  Embryotomie.  Uber  die  P)urchschneidung  des  Schlusselbeins 
(Cleidotomia).'  Knorr  and  Strassman  in  Germany,  Bonnaire  in  France, 

1  Brit.  Med.  Journ.,  April  13,  1895,  p.  808. 

2  Zent.f.  Gyn.,  June  1,  1895,  p.  5s:,. 


OPERATIONS  INVOLVING  DESTRUCTION  OF  CHILD      507 

and  Ballantyne  in  this  country,  have  drawn  special  attention  to  the 
operation.  Ballantyne's  paper1  is  the  most  complete  on  the  subject 
in  the  English  language. 

I  have  performed  the  operation  frequently  in  the  Glasgow  Maternity 
Hospital,  and  I  entirely  agree  with  all  that  has  been  written  in  its 
favour. 

The  operation  is  a  very  simple  one.  The  clavicles  are  divided 
either  by  a  pair  of  strong,  straight  scissors,  or  a  symphysiotomy  knife, 
such  as  Pinard's.  The  two  fingers  of  the  left  hand  are  passed  along 
the  ventral  aspect  of  the  child,  and  under  the  protection  of  these  the 
knife  or  scissors  is  introduced  and  the  clavicle  divided.  The  other 
clavicle  is  divided  in  a  similar  manner.  The  illustration  (Fig.  238) 
shows  a  case  in  which  both  clavicles  have  been  divided. 

The  only  danger  is  injuring  the  soft  parts  of  the  mother,  but  if 
the  operator  takes  care  to  protect  the  soft  parts  with  the  fingers  of  his 
•other  hand  when  he  introduces  the  knife  this  cannot  occur. 

1  Edin.  Obst.  Trans.,  vol.  xxvi.,  p.  24. 


CHAPTER  XXX 

MANUAL  REMOVAL  OF  PLACENTA  AND  MEMBRANES 

It  sometimes  happens  that  the  placenta  and  membranes,  instead  of 
being  expelled  some  little  time  after  the  birth  of  the  child,  are  retained 
in  the  uterus.  In  most  cases  they  are  separated,  and  are  merely 
'  retained,'  but  in  a  few  they  are  actually  '  adherent.'  According  to 
the  figures  of  a  number  of  different  writers  who  have  collected  series 
of  cases,  the  operation  of  manual  removal  of  the  placenta  was  neces- 
sary about  once  in  200  cases. 

Adherent  Placenta. — This  is  the  result  of  pathological  changes 
in  the  uterus  and  placenta,  most  commonly  a  chronic  inflammation  of 
the  uterus.  It  is  a  rare  complication — much  rarer  than  is  generally 
supposed.  It  is  more  frequent  in  pregnancies  which  terminate  pre- 
maturely than  in  those  at  full  time. 

The  recognition  of  adherent  placenta  is  not  difficult.  The  uterus 
remains  of  the  same  size  and  shape,  the  ligature  which  was  applied 
round  the  cord  at  the  vulvar  orifice  to  mark  any  descent  of  placenta 
remains  in  the  same  situation,  and  expression  of  the  placenta  is 
impossible.  Strassmann  has  pointed  out  that  as  long  as  the  placenta 
is  adherent  a  thrill  is  felt  in  the  umbilical  cord  whenever  pressure  is 
made  on  the  fundus.  Naturally,  if  there  is  a  ligature  applied  at  the 
vulvar  orifice,  the  thrill  will  be  arrested  there.  With  a  partially 
separated  placenta  this  sensation  is  not  experienced. 

A  placenta  which  is  adherent  to  any  extent  cannot  be  expressed, 
and  so,  after  waiting  for  a  certain  time,  the  hand  must  be  introduced 
into  the  uterus  and  the  placenta  and  membranes  removed.  It  may  be 
very  rightly  asked — How  long  should  one  wait  ?  As  there  is  no  definite 
time  for  placental  separation,  this  cannot  be  stated.  In  my  experi- 
ence the  placenta  takes  on  an  average  fifteen  to  twenty  minutes  to 
separate,  and  so,  if  separation  has  not  occurred  after  half  an  hour 
longer,  I  look  upon  the  condition  as  abnormal,  and  I  proceed  to  remove 
the  placenta  manually. 

Of   extreme  importance  in   performing  the   operation  is  surgical 

508 


MANUAL  REMOVAL  OF  PLACENTA  AND  MEMBRANES    509 

cleanliness,  for  the  mortality  and  morbidity  from  it  are  very  high. 
Collected  cases  of  a  variety  of  writers  show  a  mortality  of  7  to  10  per 
cent.  There  are  several  reasons  for  this.  The  operator's  hand  not 
only  comes  in  contact  with,  but  is  rubbed  repeatedly  over,  the  raw 
placental  site.  (Prior  to  delivery  all  manipulations  were  carried  on 
within  the  protecting  bag  of  membranes.)  Further,  he  is  called  upon 
to  perform  the  operation  after  a  prolonged  and  often  difficult  delivery, 
when  he  is  tired,  and  consequently  not  so  careful  in  the  precautions 
taken  against  infection.  Lastly,  in  many  cases  the  parturient  is 
extremely  exhausted  by  a  difficult  parturition  and  an  abnormal 
loss  of  blood,  and  in  consequence  her  resistance  to  infection  is 
lowered. 

Before  proceeding  to  remove  a  placenta  manually,  the  operator's 
hand  and  the  patient's  vulva  must  be  thoroughly  cleansed  over  again. 
When  the  whole  placenta  has  to  be  removed,  as  in  the  condition  we 
are  at  present  considering,  rubber  gloves  may  be  worn  with  advantage, 
but  when  it  is  a  matter  of  removing  small  portions  of  membrane  or 
placenta  I  have  found  it  necessary  to  remove  the  gloves.  One  can,  of 
course,  as  some  operators  do,  employ  cotton  gloves  for  the  purpose  ; 
the  naked  hand,  however,  is  much  the  best. 

The  operation  of  removing  the  placenta  is  not  difficult,  provided 
the  patient  is  anaesthetized,  which  should  always  be  done.  To  attempt 
the  operation  without  an  anaesthetic  has  several  disadvantages.  In 
the  first  place,  it  is  very  painful ;  but  even  more  serious  than  that  is 
the  fact  that  it  is  more  difficult  to  introduce  the  hand,  and  more 
force  is  required  to  push  it  through  the  vulvar  orifice  ;  thus  there  is 
greater  danger  of  carrying  in  organisms.  Lastly,  there  is  the  danger 
of  injuring  the  parturient  canal.  Quite  recently  a  case  was  brought 
into  hospital  where  the  medical  attendant  ruptured  the  uterus  while 
manually  detaching  a  very  adherent  placenta. 

It  was  recently  suggested  by  Peters 1  that  the  cervix  should  be 
pulled  down  by  means  of  vulsellum  forceps  while  the  assistant  pushed 
down  the  fundus.  By  this  means  the  os  externum  can  be  brought 
right  down  to  the  vulvar  orifice  and  surrounded  with  gauze,  and  the 
accoucheur  can  pass  his  hand  into  the  uterus  without  his  hand  coming 
in  contact  with  the  vaginal  wall. 

In  removing  a  placenta  that  is  adherent,  the  fingers  should  be 
passed  up  between  the  uterine  wall  and  the  placenta,  and  the  latter 
stripped  off.  Wide  sweeps  should  be  made  until  the  whole  placenta 
is  separated.  It  should  then  be  grasped  in  the  hand  (Fig.  239),  and 
the  uterus  made  to  force  out  the  hand  and  placenta  together.  During 
the  whole  process  of  removing  either  placenta  or  membranes  the 
1  Zmt.fwr.  Gyn.,  Nr.  7,  1910,  p.  225. 


.10 


Ol'KKATIVK   MIDWIFIJIV 


external   hand    must   steady  the    uterus   and    work   along  with    the 
internal. 

The  uterine  surface  after  detachment  of  the  placenta  is  always 
ragged;  it  can  never  be  made  smooth,  even  by  scraping;  so  that  it  is 
unwise  to  do  this,  for  there  is  a  distinct  danger  that  by  scraping  the 
placental  site  too  energetically  injury  may  be  done  to  the  uterine 


Fig.  239. — Manual  Removal  of  the  Placenta. 


wall.  As  I  shall  point  out  when  considering  rupture  of  the  uterus, 
-cases  of  weakening  of  the  wall  and  rupture  at  a  subsequent  pregnancy 
have  followed  such  a  procedure. 

After  the  removal  of  the  placenta  or  membranes,  it  is  advisable 
to  give  an  intra-uterine  douche  of  boiled  water  at  a  temperature  of 
116°  to  118°  F.  The  object  of  this  douche  is  to  wash  out  any  debris 
and  to  stimulate  the  uterus,  which  is  usually  in  a  condition  of  inertia 


MANUAL  REMOVAL  OF  PLACENTA  AND  MEMBRANES    511 

after  these  manipulations  and  the  deep  chloroform  anaesthesia.  It  is 
also  well  to  give  an  intracellular  injection  of  ergotine. 

Retained  Placenta  and  Membranes.  —  While  the  abnormal 
'  adhesion  '  of  placenta  to  uterine  wall  is  a  condition  quite  beyond 
one's  control,  it  is  not  so  with  '  retention  '  of  the  membranes  and 
placenta  in  whole  or  in  part.  In  most  cases — there  are,  of  course, 
many  exceptions — this  complication  is  the  result  of  improper  manage- 
ment of  the  third  stage,  especially  hurrying  it  unduly.  That  being 
so,  it  is  well  that  we  consider  what  occurs  normally  after  the  child 
is  born. 

If  one  observes  a  case  of  normal  delivery,  one  finds  that  the  uterus 
remains  retracted  and  quiescent,  just  as  it  does  after  the  birth  of  a 
first  child  in  a  twin  pregnancy.  After  a  time,  varying  from  five  to 
fifteen  minutes,  active  contractions  begin,  and  these  go  on  at  regular 
intervals,  as  they  did  during  the  first  and  second  stages.  During  the 
period  of  quiescence,  and  especially  during  contractions,  separation 
of  the  placenta  occurs.  I  do  not  propose  discussing  here  how  this 
separation  occurs.  As  is  well  known,  many  different  views  are  held 
regarding  the  matter,  some  attributing  it  to  retraction  of  the  placental 
site,  others  to  relaxation  of  the  uterine  wall  after  contraction,  while 
many  still  support  Schultze's  view  of  the  formation  of  a  retro- 
placental  hematoma.  These  are  all  still  disputed  points,  and  not 
questions  that  can  suitably  be  considered  here.  What  we  do  know  is 
that  the  placenta  takes  time  to  separate,  the  uterus  does  not  attempt 
actively  to  expel  it  for  some  little  time,  and  the  expulsion  of  the 
placenta  is  very  generally  followed  by  the  escape  of  a  considerable 
quantity  of  blood.1 

Without  doubt,  theoretically,  the  ideal  course  to  pursue  would  be 
to  leave  the  expulsion  of  the  placenta  entirely  to  Nature  ;  but  in 
practice  such  a  course  is  hardly  possible,  for,  from  statistics  in  which 
such  a  course  has  been  followed,  the  placenta  has  often  not  been 
expelled  for  many  hours.  It  is,  therefore,  universally  admitted 
that  some  assistance  should  be  given  to  the  uterus  to  expel  the 
secundines.  To  put  a  time  limit  upon  what  should  be  the  duration 
of  the  third  stage  is  quite  impossible,  for,  like  every  other  stage,  it 
must  vary  in  duration.  It  is  quite  unnecessary  for  me  to  say  that 
the  other  extreme  of  forcing  the  placenta  out  immediately  after  the 
child  is  born  is  a  highly  reprehensible  practice.  But  even  when  that 
is  appreciated,  and  a  considerable  time  is  allowed  to  elapse  before  the 
placenta  is  expelled,  portions  of  membrane  are  often  retained.  In 
great  part  I  am  convinced  this  results  from  the  erroneous  practice  of 

1  It  must  not  be  forgotten  that  the  placenta  is  often  retained  because  the  bladder 
is  over-distended. 


;i2 


OPERATIVE  M1KWII  IKY 


early  kneading  the  uterus.  The  intelligent  mid  careful  accoucheur 
knows  that  lie  slmuM  keep  his  band  upon  the  uterus  during  the  third 
stage;  but  the  mistake  he  makes  is,  instead  of  allowing  his  hand  to  lie 
quietly  on  the  uterus  and  watch  that  it  does  not  become  over-distended 
with  blood,  he  begins  to  knead  it  immediately,  with  the  result  that  he 


Fig.  240. — Method  of  expressing  the  Placenta.     (After  Bumm.) 


sets  up  a  tetanic  contraction  of  the  uterus,  especially  of  the  lower 
part  of  the  body ;  he  forgets  the  fact  that  the  uterus  must  have  a 
period  of  rest  before  it  begins  to  contract.  Personally,  I  believe, 
although  this  is  a  debated  question  and  opposed  to  the  views  of  many 
•distinguished  writers,  that  the  early  kneading  and  compression  of  the 


MANUAL.  REMOVAL  OF  PLACENTA  AND  MEMBRANES    513 

uterus  destroys  the  quiet  formation  of  the  retroplacental  hematoma, 
which,  to  my  mind,  is  a  most  important  factor  in  normal  placental 
separation  and  expulsion. 

The  course  to  pursue  is  as  follows :  Keep  the  hand  quietly  resting 
upon  the  uterus,  wait  for  fifteen  minutes  or  so  until  contractions 
commence ;  if  they  do  not  occur,  establish  periodic  contractions  by 
kneading  the  uterus  at  intervals  of  three  to  five  minutes.  Do  not 
attempt  to  expel  the  placenta  until  it  has  passed  from  the  body  into 
the  lower  uterine  segment.  This  is  indicated  by  the  altered  shape  of 
the  uterus  ;  the  fundus  rises  up  higher,  and  the  shape  comes  to  be  less 
globular.     In  addition,  more  of  the  cord  slips  out  of  the  vulvar  orifice, 


'v 


x 


Fig.  241. — Removing  the  Membranes  by 
twisting  the  Placenta  so  that  the  Mem- 
branes are  formed  into  a  Twisted  Cord. 


Fig.  242. — Removing  the  Membranes  by- 
Direct  Traction  upon  them. 


and  traction  upon  the  cord  indicates  that  the  placenta  is  not  as 
intimately  connected  with  the  uterus  as  it  was. 

By  the  end  of  thirty  minutes  or  so,  if  the  placenta  has  passed  out 
of  the  body  of  the  uterus,  pressure  may  be  exerted  on  the  fundus,  and 
the  placenta  slowly  forced  out  of  the  vagina. 

The  method  of  expressing  the  placenta  generally  employed  is 
associated  with  Crede's  name,  although  there  is  no  doubt  that  the 
Rotunda  School  rightly  claims  priority.  The  operation  is  carried  out 
as  follows  : 

The  uterus  is  kneaded  firmly  by  the  hand  until  it  actively  con- 
tracts— the  fingers  are  passed  behind  and  the  thumb  in  front  of 
the  uterus  (Fig.  240).     Not  only  is  it  profitless  to  try  and  express 

33 


514  OPERATIVE  MIDWIFERY 

the  placenta  before  a  contraction  is  established,  but  there  is  even  the 
danger  that  by  trying  to  do  so  an  inversion  of  the  uterus  may  be  pro- 
duced. Having  secured  an  active  contraction,  the  uterus  is  squeezed 
between  the  thumb  and  fingers,  and  the  placenta  is  slowly  forced  out 
of  the  vagina.  No  great  force  is  required,  as  a  rule — indeed,  if  it  is 
necessary,  it  is  evidence  that  the  placenta  is  not  yet  ready  to  be  forced 
out.  As  I  have  already  indicated,  the  passage  of  the  placenta  is  often 
retarded  by  contraction  of  the  lower  part  of  the  body  (Bandl's 
ring).  This,  as  stated,  often  results  from  too  early  kneading  of  the 
uterus. 

Special  care  must  be  taken  that  the  after -birth  is  not  expelled 
too  rapidly,  for  then  the  membranes  are  very  liable  to  be  torn  and 
retained. 

As  the  placenta  appears  at  the  vulvar  orifice  it  should  be  received 
by  the  hand  of  the  accoucheur,  and  the  membranes  should  be  care- 
fully removed  by  traction.  It  is  frequently  recommended  that  as 
the  placenta  is  removed  it  should  be  twisted  so  that  the  membranes 
are  formed  into  a  cord  (Fig.  241).  Personally,  I  am  very  doubtful 
about  the  wisdom  of  this  common  procedure,  and  certainly  I  think 
it  unwise  when  the  membranes  show  signs  of  tearing  along  the 
edge  of  the  placenta.  It  is  better,  I  think,  if  there  is  any  difficulty 
with  the  membranes,  to  grasp  them  and  exert  gentle  traction  upon 
them  (Eig.  242).  I  have  sometimes  sat  holding  them  for  many 
minutes,  until  the  spasm  of  the  uterine  muscle  has  quite  passed  off. 
Occasionally,  when  there  is  a  little  difficulty  in  removing  the  mem- 
branes, the  sudden  withdrawal  of  the  hand  that  is  pressing  down  the 
fundus  allows  the  latter  to  spring  back  a  little,  with  the  result  that 
the  membranes  come  away  easily. 

Manual  Removal  of  Portions  of  Placenta  and  Membranes. — 
Should  it  happen  that  a  portion  of  the  membranes  is  retained  in  the 
uterus,  the  question  will  naturally  arise  as  to  whether  or  not  the 
hand  should  be  introduced  into  the  uterus  for  their  removal.  The 
answer  is  sometimes  a  little  difficult.  I  certainly  think  the  mem- 
branes should  be  removed  manually  if  the  bulk  of  them  is  retained ; 
but  when  only  small  portions  are  left  behind,  or  when  one  is  doubtful 
as  to  whether  or  not  any  is  retained,  I  think  the  wiser  course  is  not 
to  insert  the  hand,  because  of  the  great  danger  of  introducing  in- 
fection. The  statistics  of  all  maternity  hospitals  prove  that  this 
danger  is  very  great,  and  my  personal  experience  in  private  practice 
is  the  same.  If  one  removes  any  portion  of  membrane  that  may  be 
in  or  projecting  into  the  vagina,  the  expulsion  of  the  remainder  may 
safely  be  left  to  Nature,  as  it  will  come  away  in  a  few  days  in  the 
lochial  discharge.     Should  there  arise,  by  any  chance,  in  such  cases 


MANUAL  EEMOVAL  OF  PLACENTA  AND  MEMBRANES    515 

a  rise  of  temperature  of  any  other  symptom  of  infection,  intra-uterine 
douches  must  be  given.  I  need  hardly  remind  my  readers  that  in 
examining  the  membranes  both  the  chorion  and  amnion  must  be 


Fig.  243. — Placenta  Succenturiata.     (Author's  Collection.; 


looked  at.  Very  frequently  the  amnion  comes  away  without  the 
chorion — indeed,  this  is  most  commonly  the  case  where  portions  of 
membranes  are  retained. 

So  far  I  have  purposely  not  mentioned  the  retention  of  portions 


516  OL'EUATIYK   MIDWIFERY 

of  placenta,  for  thai  condition  is  on  quite  a  different  footing  to  reten- 
tion of  small  portions  of  membranes.  No  portion  of  placenta  should 
ever  be  left  behind;  consequently,  even  in  cases  of  doubt  with  regard 
to  the  placenta,  the  hand  should  be  introduced.  It  may  sometimes 
happen  that  a  placenta  succenturiata  (Fig.  248)  is  left  behind  in  the 
uterus.  Such  a  condition  is  impossible  of  recognition,  for,  although 
in  such  cases  a  portion  of  the  membranes  is  wanting,  the  operator 
naturally  thinks  that  only  membranes  are  retained. 

In  removing  the  whole  placenta,  adherent  or  retained,  I  advise 
using  a  rubber  glove.  I  have  found,  however,  that  it  is  quite  im- 
possible to  remove  small  portions  of  placenta  or  membranes  with  the 
gloved  hand. 

One  should  try  to  remove  the  membranes  with  the  first  introduc- 
tion of  the  hand,  for  each  succeeding  introduction  of  the  hand  increases 
the  risk  of  infection. 

The  later  effects  of  retained  portions  of  placenta,  and  also  to  a 
slight  extent  of  retained  membranes,  are  saprsemia,  secondary  post- 
partum haemorrhage,  subinvolution  of  the  uterus,  and  placental  polypus 
with  menorrhagia. 


CHAPTER  XXXI 

INTERRUPTED  GESTATION— ABORTION  AND  HYDATIDIFORM 

MOLE 

In  considering  interrupted  gestation,  it  is  customary  to  distinguish 
two  distinct  groups,  according  as  the  pregnancy  is  interrupted  before 
or  after  the  foetus  is  viable,  interruption  before  the  viable  age  being 
termed  '  abortion '  and  after  that  time  '  premature  labour.'  The 
viable  age  generally  fixed  is  twenty-eight  weeks,  or  seven  lunar 
months. 

Abortion. 

Abortion,  or  miscarriage,  may  be  defined  as  interruption  of  preg- 
nancy before  the  fostus  is  viable — that  is,  before  the  twenty-eighth 
week.  In  some  text-books  a  distinction  is  drawn  between  '  abortion  ' 
and  '  miscarriage,'  abortion  being  the  term  applied  up  to  the  end  of 
the  sixteenth  week  and  miscarriage  from  that  time  until  the  twenty- 
eighth  week.  Such  a  distinction  has  been  very  generally  given  up, 
for  clinically  the  two  are  the  same,  so  that  the  two  terms  are  used 
indiscriminately,  with  the  exception,  perhaps,  that  abortion  is  the 
more  technical  and  miscarriage  the  more  popular. 

It  is  an  extremely  common  occurrence,  this  interruption  of  gesta- 
tion. Certainly  half,  if  not  more,  of  all  married  women  abort  at  least 
once,  or,  to  put  it  in  another  way,  at  least  one  in  every  seven  preg- 
nancies terminates  in  abortion.  But  abortions  are  more  frequent  than 
even  these  figures  would  suggest,  for  many  of  the  cases  occurring 
early  in  pregnancy  are  never  recognized,  either  by  the  women  them- 
selves or  by  their  medical  attendants.  The  small  ovum  is  expelled 
with  some  blood,  which  is  considered  that  of  a  delayed  or  a  premature 
menstrual  period. 

Abortions  come  under  our  notice  most  generally  in  the  third  and 
fourth  lunar  months,  because  at  that  time  the  attachment  of  the 
ovum  to  the  uterus  is  not  very  firm,  and  because  if  they  occur  before 
that  time  they  pass  by  unrecognized  or  without  any  attention  being 

517 


518  OPERATIVE  MIDWIFERI 

given  them.  Criminal  abortions  are  usually  induced  at  this  time 
also,  as  before  the  third  month  there  is  always  some  uncertainty  as 

to  whether  pregnancy  exists  or  not;  while  after  the  fourth  month, 
concealment  of  the  condition  being  impossible,  it  is  considered  neces- 
Bary  not  to  delay  longer. 

The  time  that  would  have  been  a  menstrual  period  had  pregnancy 
not  existed  is  especially  dangerous,  for  although  menstruation  is 
suppressed  during  pregnancy,  it  is  not  uncommon  to  find  loc;il  and 
general  disturbances  periodically  manifesting  themselves.  Again,  if 
a  miscarriage  has  once  occurred,  it  is  liable  to  recur,  because  the 
pathological  condition  causing  the  abortion  remains  so  often  uncor- 
rected ;  indeed,  it  is  sometimes  aggravated  by  the  miscarriage,  for 
women,  more  particularly  amongst  the  poorer  classes,  do  not  take 
anything  like  the  same  care  of  themselves  after  an  abortion  as  after  a 
labour  at  full  time. 

Etiology. 

In  discussing  this  subject  I  shall  be  very  brief.  The  conditions 
which  bring  about  abortions  are  both  numerous  and  varied.  They 
all,  however,  act  in  two  ways  :  they  stimulate  the  uterus  to  contract 
and  they  interfere  with  the  utero-placental  circulation.  In  most 
abortions  the  separation  precedes  the  contractions,  but  in  a  few  that 
is  not  so ;  the  contractions  first  occur,  and  they  bring  about  the 
separation. 

The  conditions  on  the  side  of  the  foetus  which  give  rise  to  abortion 
are  for  the  most  part  disease  of  itself  and  its  membranes.  The  most 
important  disease  is,  of  course,  syphilis.  In  most  cases  of  disease  of 
the  ovum  the  circulation  on  the  fcetal  side  of  the  placenta  becomes 
disturbed,  placental  haemorrhage  occurs,  and  finally  the  circulation 
is  arrested.  The  dead  ovum  then  becomes  a  foreign  body,  which 
remains  for  a  variable  time,  until  uterine  contractions  are  set  up  and 
bring  about  its  expulsion. 

The  maternal  causes  are  so  numerous  and  varied  that  I  have 
thought  it  well  to  divide  them  into  the  following  groups  : 

[a)  Diseased  Conditions  in  the  Reproductive  Organs,  especially 
such  conditions  as  endometritis,  metritis,  retro-displacement  of  the 
uterus,  and  tumours  of  the  uterus.  These  varied  diseases  all  act  in 
the  same  way :  they  favour  pathological  changes  in  and  separation 
of  the  placenta.  Of  them  all,  by  far  the  most  important  is  endo- 
metritis, and  I  have  no  hesitation  in  saying  that  at  least  70  per  cent. 
of  all  cases  of  abortion  are  caused  by  this. 

(b)  Diseased  Conditions  in  the  Other  Systems  of  the  Body — 
for   example,    in    the   alimentary,    diarrhoea   and   vomiting  ;    in    the 


INTEKKUPTED  GESTATION  519 

nervous,  chorea  and  epilepsy  ;  in  the  respiratory,  bronchitis  and 
pneumonia ;  in  the  vascular,  valvular  disease  of  the  heart ;  in  the 
urinary,  nephritis  and  cystitis.  Such  conditions  act  differently  in 
bringing  about  miscarriage.  For  instance,  in  severe  coughing  or 
excessive  vomiting  the  uterus  may  be  directly  stimulated  to  contract, 
or  in  diarrhoea  it  may  be  reflexly  stimulated  to  do  so.  In  chronic 
valvular  disease  of  the  heart  passive  congestion  and  haemorrhage 
into  the  placenta  are  liable  to  occur,  and  the  uterus  is  stimulated  to 
contract  by  the  excessive  carbonic  acid  in  the  blood,  the  result  of 
defective  aeration. 

(c)  Poisons  circulating-  in  the  Blood. — In  some  these  are  the 
poisons  of  the  specific  fevers.  The  poison  of  syphilis  is  far  the  most 
striking  example,  and  it  is  undoubtedly  accountable  for  a  very  large 
number  of  abortions  ;  but,  besides  syphilis,  there  are  others,  such  as 
those  of  small-pox,  typhus,  enteric,  malaria,  etc.  Some  of  these 
poisons  directly  kill  the  child,  but  many  bring  about  abortion,  because 
the  waste  material  produced  by  the  high  temperature  stimulates  the 
uterus  to  contract,  and  favours  passive  congestion  of  the  placenta. 

In  another  group  of  cases  the  poisons  are  simply  the  result  of 
defective  metabolism  and  elimination.  Eclampsia,  icterus,  and  many 
cases  of  hyperemesis  gravidarum,  are  good  examples.  In  yet  another 
class  the  poisons  are  metallic,  slowly  absorbed  into  the  system. 
Examples  of  this  are  found  in  lead  and  mercury  workers.  Lastly, 
in  certain  cases  the  poison  is  some  drug,  such  as  ergot,  savin,  etc., 
taken  intentionally  or  accidentally.  Each  of  these  causes  abortion 
by  stimulating  the  uterus  to  contract  either  directly  or  through  the 
nervous  system. 

{d)  Accidental  Conditions,  such  as  Falls,  Blows,  and  Injuries. 
— These,  acting  directly  or  indirectly  through  the  nervous  system, 
set  up  uterine  contractions.  Also  sudden  emotion  may  occasionally 
bring  about  a  miscarriage.  In  this  connexion,  however,  I  would 
remark  that  the  healthy  uterus  can  stand  a  great  deal,  and  that 
abortions  are  comparatively  rarely  caused  by  accidents.  There  is 
usually  some  disease  of  the  uterus. 

(e)  Criminal  Abortions.— The  abortion  is  induced  by  the  passage 
of  instruments  into  the  uterine  cavity,  by  the  taking  of  oxytocic  drugs, 
by  jumping  from  a  height,  etc. 

(/)  But,  besides  all  these  causes,  there  yet  remains  a  number  of 
cases  where,  as  far  as  one  can  discover,  no  cause  exists  beyond  an 
irritability  on  the  part  of  the  uterus  which  allows  the  pregnancy  to 
advance  only  a  certain  stage,  and  then  time  and  again  throws  off  the 
product  of  conception.  This  has  led  some  to  speak  of  the  uterus  as 
having  contracted  the  habit  of  aborting.     Eepeated  abortions,  how- 


•>:.'<»  OPERATIVE  MIDWIFERY 

ever,  are  more  usually  tlie  result  of  special  diseased  conditions,  which, 
if  carefully  searched  for,  will  lit-  discovered.  It,  therefore,  Leads  to 
errors  of  treatment  if  one  contents  oneself  with  a  diagnosis  of  '  habit 
abortion.'  Still,  in  spite  of  the  most  careful  examination,  there  are 
cases  where  a  peculiar  irritability  of  the  uterus  seems  to  he  the  only 
cause.  That  this  is  probably  s  satisfactory  enough  explanation  in 
such  cases  is  evidenced  hy  the  fact  that  the  irritability  of  the  uterus 
varies  in  different  individuals.  One  does  encounter  cases  where 
women  abort  on  slight  emotional  disturbance  or  trivial  accident. 
Again,  in  cases  of  induction  of  premature  labour — one  finds  that 
labour  is  brought  about  with  the  greatest  ease  in  some,  while  in 
others  it  is  most  difficult — I  have  seen  the  cervix  dilated  and  bougies 
inserted  without  avail. 

Symptomatology  and  Diagnosis. 

The  symptoms  of  abortion  are  pains  or  uterine  contractions, 
haemorrhage,  and  dilatation  of  the  cervix.  Occasionally  there  are 
certain  discomforts,  spoken  of  as  prodromal  symptoms,  such  as  a 
feeling  of  weight  in  the  pelvis,  irritability  of  the  bladder,  a  mucous 
or  sero-mucous  discharge ;  but  they  are  really  of  no  importance  or 
value  from  a  diagnostic  point  of  view. 

The  first  symptom  may  be  haemorrhage  or  pain  ;  most  commonly 
it  is  haemorrhage.  The  extent  of  the  haemorrhage  varies  greatly,  and 
is  sometimes  quite  alarming.  Following  the  haemorrhage,  and,  as  I 
have  said,  sometimes  before  it,  are  '  pains '  referred  to  the  back  and 
hypogastrium.  By  multiparas  they  are  described  as  resembling  labour 
pains,  but  by  primigravidae  they  are  often  described  as  resembling 
intestinal  colic.  In  abortion  in  the  earlier  months  the  pains  are  much 
less  severe  than  in  abortions  which  occur  later ;  indeed,  the  ovum 
may  in  the  first  and  second  month  be  expelled  with  little  or  no  pain. 
Dilatation  always  follows  the  haemorrhage  and  pains,  and  its  extent 
depends  on  the  size  of  the  ovum  to  be  expelled. 

The  diagnosis  of  abortion  in  most  cases  is  not  difficult.  The 
history  of  suppression  of  one  or  more  menstrual  periods  and  other 
symptoms  of  pregnancy,  the  haemorrhage,  and  the  pains,  make  it  clear 
generally  that  one  has  to  deal  with  this  condition.  Before  definitely 
deciding  upon  abortion,  one  must  exclude  the  possibility  of  extra- 
uterine pregnancy,  for  at  an  early  stage  they  may  have  every 
symptom  in  common.  Many  may  think  I  am  laying  undue  stress 
upon  this  danger,  and  may  say  extra-uterine  pregnancy  is  such  a  rare 
occurrence  it  may  be  put  out  of  account ;  but  that  is  not  so  :  it 
is  now  known  to  be  by  no  means  uncommon.     As  evidence  of  the 


INTERRUPTED  GESTATION  521 

necessity  of  emphasizing  this  danger  of  overlooking  an  extra- uterine 
pregnancy  and  diagnosing  an  ordinary  abortion,  I  may  mention  that 
in  fully  30  per  cent,  of  the  cases  of  extra-uterine  pregnancy  which  I 
have  had  to  deal  with  the  mistake  has  been  made.  In  most  cases- 
a  careful  bimanual  examination  reveals  which  of  the  two  conditions 
exists.  I  shall  go  into  this  matter  more  fully  in  the  succeeding 
chapter,  when  discussing  extra-uterine  pregnancy. 

But  other  conditions  besides  extra-uterine  pregnancy  may  simulate 
abortion — for  example,  ulcerative  conditions  of  the  cervix,  polypi  of 
the  cervix,  and  sometimes  even  menstruation  during  pregnancy,  call 
for  mention.  In  these  conditions  there  are  no  '  pains,'  the  bleeding 
is  very  rarely  profuse,  and  there  is  no  dilatation  of  the  cervix.  Still, 
each  may  resemble  '  threatened  abortion,'  and  only  a  careful  examina- 
tion will  settle  which  it  is. 

Malignant  disease  or  a  polypus  of  the  cervix  should  not  be 
difficult  of  recognition,  but  menstruation  during  pregnancy  may  be 
very  confusing.  In  the  cases  which  I  have  seen  this  periodic  dis- 
charge has  occurred  at  the  usual  regular  intervals,  has  always  been 
scanty,  and  has  never  continued  after  the  third  month.  There  are, 
however,  cases  on  record  where  it  has  continued  during  pregnancy. 
I  have  never  seen  such  cases;  I  believe  they  are  very  rare  indeed. 
In  all  eases  where  haemorrhage  recurs  during  pregnancy  the  possi- 
bility of  placenta  praavia  should  be  considered. 

The  cases  in  which  I  have  had  greatest  difficulty  are  where,  shortly 
after  delivery  and  when  menstruation  is  suppressed,  a  decision  has  to- 
be  come  to  between  post-partum  metritis  and  endometritis  and  an 
early  miscarriage — indeed,  I  have  once  or  twice  found  it  impossible  to 
decide  in  such  cases.  Fortunately,  the  treatment  in  both  is  much 
the  same,  for  if  the  bleeding  continues  after  rest,  etc.,  the  uterus  must 
be  explored  with  the  fingers  or  the  curette. 

I  would  sum  up  the  matter  of  diagnosis  in  cases  of  supposed 
abortion  by  advising  every  one  to  satisfy  himself  on  the  following 
points  :  (1)  Is  the  woman  really  pregnant '?  (2)  Is  the  pregnancy 
intra-  or  extra-uterine?  (3)  If  intra-uterine,  is  abortion  inevitable,  or 
is  it  only  threatened  ? 

Varieties  of  Abortion  and  their  Differentiations. 

Having  satisfied  oneself  that  the  pregnancy  is  intra-uterine,  the 
next  thing  to  decide  is  whether  the  abortion  is  threatening  or  in- 
evitable. To  decide  this  question  is  not  always  easy,  especially  if  all 
blood-clots,  etc.,  have  been  thrown  out  and  are  not  available  for 
inspection.      If   the  bleeding   is  at  all  pronounced,   the  pains   very 


522  OPERATIVE  MIDWIFKllV 

severe,  and  the  os  distinctly  dilated,  one  always  considers  the  abortion 
inevitable  ;  but  if  there  is  only  moderate  pain  and  hemorrhage,  the 
miscarriage  may  often  be  prevented  by  suitable  treatment.  In  all 
cases  of  doubt  one  must  temporize  and  treat  the  abortion  as  only 
threatening.  This  not  infrequently  involves  keeping  the  patient 
under  observation  in  bed  for  some  time.  In  these  cases  one  may 
sometimes  be  uncertain  as  to  whether  or  not  the  pregnancy  is  going 
to  continue  on  account  of  a  slight  discharge  persisting.  If  it  is  con- 
tinuous and  of  a  brownish  character,  in  spite  of  rest  in  bed,  the  ovum  is 
generally  dead  ;  but  if  there  are  occasional  slight  bright  hemorrhages, 
I  have  often  seen  the  pregnancy  continue,  and  ultimately  terminate 
quite  satisfactorily.  The  patient  must  be  kept  in  bed  until  all 
hemorrhage  ceases.  Let  me  once  <i<i<iin  remind  my  readers  that 
haemorrhages  recurring  <!iirin</  pregnancy  should  make  one  very 
suspicious  of  placenta  prawha. 

Having  settled  in  a  particular  case  that  an  abortion  is  unavoidable, 
one  has  next  to  decide  whether  it  is  '  complete  '  '  incomplete,"  or 
'  missed.' 

An  abortion  is  said  to  be  complete,  when  the  whole  product  of 
conception  is  expelled.  In  the  early  months  the  ovum  is  expelled 
intact  :  later,  however,  the  expulsion  more  nearly  resembles  an 
ordinary  labour,  and  we  usually  have  rupture  of  the  membranes, 
expulsion  of  the  foetus,  the  placenta  and  membranes  following  after  a 
longer  or  shorter  interval.  Sometimes,  however,  even  in  the  later 
months  the  whole  sac  with  placenta  attached  is  expelled  unruptured. 
I  have  seen  this  occur  even  at  the  end  of  the  seventh  month. 

By  incomplete  abortion  one  means  the  retention  in  the  uterus  of 
part  of  the  ovum.  In  the  first  three  months  before  the  fusion  of 
decidua  capsularis  (reflexa)  and  vera  (Fig.  244)  it  very  frequently 
happens  that  the  ovum  with  the  reflexa  is  expelled  and  the  vera  is 
left  behind.  I  have  even  seen  the  whole  vera  expelled  and  the  ovum 
and  serotina  retained,  and  that  is  very  confusing,  especially  if  the 
ovum  is  inserted  in  the  upper  corner  of  the  uterine  cavity  ('  angular 
pregnancy  '),  for  the  case  may  very  closely  resemble  an  extra-uterine 
pregnancy.  Such  a  case  is  fully  described  in  the  succeeding  chapter 
(p.  562). 

Later  in  pregnancy,  after  the  formation  of  the  placenta,  portions 
of  the  membranes  and  placenta,  or  even  the  entire  placenta,  may  be 
retained.  Sometimes  a  very  small  portion  remaining  behind  forms 
the  centre  round  which  blood  coagulates  (placental  polypus).  In 
practice  it  is  often  a  matter  of  extreme  difficulty  to  tell  whether  an 
abortion  is  complete  or  incomplete,  and,  indeed,  unless  one  has  all  the 
•tissues  expelled  from    the  uterus  for  examination,  or  can    pass   the 


INTERRUPTED  GESTATION 


523 


fingers  through  the  os  and  explore  the  interior  of  the  uterus,  it  is 
quite  impossible  to  speak  with  certainty.  The  size  of  the  uterus,  the 
amount  of  the  discharge,  and  the  dilatation  of  the  canal,  will  help  one 
to  decide :  for  if  there  is  anything  retained  the  os  remains  more 
patent,  bleeding  continues,  and  involution  is  retarded  ;  while  if  every- 


Fig.  244. — Uterus  with  Ovum  of  about  Three  Months. 

There  has  been  a  window  cut  in  the  uterus  wall  and  in  the  decidua  reflexa.  A  piece  of 
whalebone  passed  through  the  cervix  presses  upon  the  decidua  reflexa.  There  is  still  a 
space  between  the  decidua  reflexa  and  the  decidua  vera.  (Allen  Thomson's  Collection, 
Hunterian  Museum.) 


thing  has  been  expelled,  the  os  becomes  closed,  the  uterus  diminishes 
in  size,  and  the  hemorrhage  and  discharge  cease.  Theoretically  that  is 
perfectly  correct,  but  one  meets  with  many  exceptions.  Quite  recently, 
in  considering  the  subject  with  my  students,  I  demonstrated  a  case  as 
presenting  all  the  features  of  complete  abortion — the  os  was  closed, 


524 


OPERATIC  i:  MJI>\\  III  i;V 


there  had  been  practically  no  discharge  for  -mum.  daw-,  and  the  uterus 
appeared  of  about  normal  size.  In  spite  of  that,  however.  I  explored 
the  uterus,  and  removed  a  large  piece  of  placenta.     1  alwaye  explore 

the  uterus  unless  I  am  absolutely  certain  from  what  1  have  seen  that 
everything  has  come  away. 

In  cases  of  incomplete  abortion,  when  only  a  small  portion  of 
tissue  is  left  behind,  it  may  he  some  time  before  there  is  any  evidence 
that  such  is  the  case.  Sooner  or  later  it  will  manifest  itself  by 
monorrhagia,  abdominal  uneasiness,  and  Blight  sapraemia. 

There  remains  another  variety,  termed  missed  abortion.  In  it 
the  ovum  dies,  the  pains  and  hemorrhage  cease,  and  the  ovum  is 


Fig.  245. — Fleshy,  Carneous,  or  Hemorrhagic  Mole,  from  a  case  of  Missed  Abortion. 

(Author's  Collection.) 


retained  for  weeks  or  months.  In  such  cases  the  symptoms  of 
pregnancy,  such  as  swelling  of  the  breasts  and  morning  sickness,  dis- 
appear, the  uterus  remains  of  the  same  size,  and  menstruation'con- 
tinues  suppressed,  although  there  is  occasionally  a  slight  brownish 
discharge.  The  diagnosis  of  this  form  of  abortion  is  by  no  means 
easy.  There  is  not  usually  any  difficulty  in  recognizing  the  existence 
of  pregnancy,  but  there  is  in  deciding  whether  the  ovum  is  alive  or 
dead.  Time  clears  matters  up,  for  if  the  ovum  is  alive  the  uterus 
steadily  increases,  while  if  it  is  dead  it  remains  stationary.  The  ovum 
expelled  in  such  cases  (fleshy,  carneous,  tuberose,  or  hemorrhagic  mole) 
presents  peculiar  appearances  (Fig.  245).    The  fu-tus  may  entirely  (lis- 


INTERRUPTED  GESTATION  525 

•appear,  or  only  a  trace  of  it  may  remain ;  but  if  it  has  developed  some 
weeks  before  its  death  occurred,  it  becomes  mummified.  The  length 
of  time  an  ovum  or  part  of  an  ovum  can  be  retained  in  the  uterus  is 
variable,  but  very  often  it  is  retained  until  such  time  as,  had  pregnancy 
continued,  normal  labour  would  have  come  on.  Occasionally  it  is 
retained  eleven  months.  Berry  Hart1  pointed  this  out  several  years 
ago.  He  wrote  :  '  It  looks,  therefore,  as  if  the  uterus  were  occasionally 
cheated  by  the  mole,  which  forms  at  or  about  the  second  or  third 
month,  and  may  be  retained  for  the  nine  months  given  to  a  normal 
pregnancy.'  Hart,  in  the  same  paper,  remarks :  '  So  far  as  my 
reading  goes,  no  case  has  gone  beyond  eleven  months.  There  are, 
however,  one  or  two  which  have  been  recorded  where  the  dead  ovum 
was  retained  for  years.     They  are  considered  by  Graefe.'2 


Treatment. 

Prophylactic. — "Where  previous  abortion  has  occurred  the  patient 
should  be  carefully  examined,  and  the  cause  of  the  abortion  deter- 
mined, if  possible.  Diseased  conditions,  such  as  chronic  inflammation 
of  the  uterus  or  appendages,  should  be  treated,  displacements  cor- 
rected, and  any  reflex  irritation  removed.  Above  all,  the  possibility 
of  syphilis  should  be  considered,  and  if  there  is  the  slightest  suspicion 
of  this  poison  being  present,  both  parents  should  undergo  a  course  of 
-antisyphilitic  treatment  for  twelve  months  at  least  before  another 
pregnancy  is  permitted. 

In  very  troublesome  cases,  where  no  distinct  cause  can  be  dis- 
covered, it  is  well  to  begin  treatment  by  advising  a  cessation  of  all 
marital  intercourse  for  some  months,  and  this  is  best  accomplished  by 
sending  the  patient  from  home.  During  these  months  of  absence  the 
general  health  should  be  improved  with  suitable  exercise,  massage, 
and  general  tonics,  such  as  iron,  quinine,  or  strychnine.  It  is 
often  advisable  to  curette  the  uterus  before  permitting  another 
pregnancy. 

"Whenever  pregnancy  occurs  all  intercourse  must  be  again  stopped. 
If  syphilis  was  the  suspected  cause,  antisyphilitic  treatment  must  be 
continued  during  the  whole  of  the  pregnancy.  In  other  cases  chlorate  of 
potash  (5  grains  thrice  daily)  is  recommended.  It  is  supposed  that  this 
drug  has  a  beneficial  effect,  because  it  parts  so  readily  with  its  oxygen  ; 
the  amount  of  oxygen  given  up,  however,  must  be  very  small  indeed. 
I  usually  prescribe  the  drug,  and  continue  it  throughout  the  pregnancy, 

1  Brit.  Med.  Joztrn.,  October  24,  1896,  p.  1189. 

2  '  Festschrift  Carl  Ruge,'  Berlin,  1896. 


526  Ol'KliATlYE  MIDWIFERY 

unless  it  causes  gastric  irritation.  The  bowels  must  be  most  carefully 
regulated.  A  diet  which  gives  the  least  amount  of  waste  should  be 
prescribed.  The  patient  should  be  encouraged  to  drink  considerable 
quantities  of  fluids  between  meals,  for  it  is  most  important  to  keep 
up  elimination.  Fresh  vegetables,  if  the  digestion  is  good,  and  fruit- 
juice  should  be  recommended. 

It  is,  of  course,  impossible  to  say  how  far  such  treatment  does 
good,  for,  in  addition  to  it,  I  have  always  insisted  that  my  patients 
remained  absolutely  at  rest  in  bed  throughout  the  greater  part  of  the 
pregnancy.  The  importance  of  this  absolute  rest  in  bed  cannot  be 
too  strongly  emphasized.  It  is  very  irksome  for  the  patient.  J//<  r  a 
few  months,  she  may  be  allowed  a  little  more  liberty  ;  for  it  is  in  the 
earlier  months,  when  the  placenta  is  being  formed,  that  it  is  so 
extremely  important  to  maintain  a  quiet  circulation  in  the  uterus. 

Threatened  Abortion. — -A  threatening  of  abortion  should  be 
treated  by  at  once  confining  the  woman  to  bed  and  giving  some 
sedative.  Personally,  I  always  give  opium  or  morphia.  Laudanum 
or  Battley's  solution  by  the  mouth,  or  a  morphia  suppository,  are  the 
best ;  morphia  given  hypodermically  is  not  so  good.  Liquid  extract 
of  Viburnum  prunifolium,  twice  daily,  is  strongly  recommended 
by  American  obstetricians.  Williams1  recommends  the  following 
suppository :  Codi*  sulphat.,  gr.  ss. ;  ext.  hyoscyami,  gr.  i. ;  ext. 
viburni  prunifolii,  gr.  v. ;  ol.  theobroma?,  q.s.  This  is  to  be  ad- 
ministered every  four  hours.  Chloral,  with  or  without  bromide  of 
potash,  is  also  recommended,  but  personally  I  have  found  morphia 
or  opium  do  most  good.  Ergot,  in  small  doses,  is  said  to  be  bene- 
ficial. Given  in  that  way,  it  is  claimed  that  it  arrests  bleeding, 
without  setting  up  uterine  contractions.  For  my  part,  I  believe  that 
the  cases  which  terminate  satisfactorily  do  so  in  spite  of  the  ergot. 

The  diet  should  be  very  simple,  only  cold  fluids  being  given. 
The  patient  should  be  kept  in  bed  until  the  bleeding  has  ceased  for 
some  time. 

The  great  difficulty  is  to  know  when  the  abortion  has  ceased  to 
be  threatening  and  has  become  unavoidable.  In  the  early  months 
a  continuation  of  the  bleeding,  even  if  the  pains  are  absent,  usually 
means  that  the  fcetus  is  dead,  and,  consequently,  the  sooner  it  is 
removed  the  better.  In  many  cases  one  can  only  decide  by  examining 
the  uterus  from  time  to  time,  and  seeing  if  it  is  enlarging.  This, 
as  I  have  already  indicated,  involves  weeks  of  suspense  to  the 
patient.  When  pregnancy  is  more  advanced,  repeated  auscultations 
may  be  of  service,  as  giving  information  regarding  the  life  of  the 
foetus. 

1  'Obstetrics,'  1910,  p.  618. 


INTERRUPTED  GESTATION 


527 


Inevitable  Abortion.  —  When  the  abortion  is  inevitable,  the 
sooner  the  uterus  is  emptied  the  better.  The  ease  with  which  this 
can  be  done  depends  upon  the  degree  of  dilatation  of  the  cervix. 

In  emptying  the  uterus  in  cases  of  abortion,  the  very  greatest 
care  must  be  taken  in  thoroughly  cleansing  the  vagina  and  vulva, 
because,  with  the  continuous  hemorrhagic  discharge,  those  parts  are 
generally  septic. 

In  the  early  months,  if  two  fingers  can  be  passed  into  the  uterus, 
the  ovum  can  usually  be  separated  completely,  especially  if  the  other 


Fig.   246. — Method  of  expressing  the  Ovum. 


hand  presses  down  the  uterus  from  the  abdomen.  Sometimes, 
although  separated,  the  ovum  slips  round  the  fingers,  and  cannot  be 
caught  hold  of.  It  should  then  be  removed  by  '  expression  '  or  by 
ovum  forceps.  Expression  (Fig.  246)  is  carried  out  by  compressing 
the  body  of  the  uterus  between  the  two  hands.  The  internal  fingers 
press  the  body  from  the  anterior  fornix  and  the  external  press  it 
from  the  abdomen.  One  must  only  express  with  the  internal  fingers 
in  the  anterior  fornix.  If  an  attempt  is  made  to  do  it  from  the 
posterior,  there  is  danger  of  lacerating  the  vault  of  the  vagina.  This 
accident  actually  occurred  some  years  ago  in  the  hands  of  a  prac- 
titioner of  wide  experience.     He  asked   me  to  see  the  case  in  con- 


528  OPEIIATIYE  MIl^VIFKIiY 

saltation  with  him,  and  I  discovered  that,  although  the  vault  of 
the  vagina  was  torn,  bhe  peritoneal  cavity  wras  not  opened  into. 
The  wound  was  plugged,  and  the  patient  made  quite  ;i  satisfactory 
recovery. 

A  very  convenient  way  of  removing  the  ovum  when  it  i>  detached 
is  by  means  of  the  ovum  forceps  (Fig.  247). 

If  the  os  is  not  dilated,  this  must  be  done  before  the  ovum  can 
be  removed.  It  may  be  carried  out  in  various  ways.  The  one 
generally  employed  is  to  plug  the  cervix  and  vagina  with  sterilized 
gauze.  This  operation  should  always,  when  possible,  be  carried  out 
under  an  anaesthetic,  for  one  can  then  perform  it  much  more 
thoroughly  and  aseptically.  The  very  greatest  care  must  be  taken 
in  cleansing  the  part  about  the  vulva  and  vagina.  The  cervix  is 
seized  with  vulsellum  forceps,  great  care  being  taken  not  to  put  too 


Fig.  217. — Ovum  Forceps. 

much  traction  on  the  instrument,  as  the  cervix,  being  so  soft,  readily 
tears.  A  retractor  is  then  introduced,  and  the  posterior  vaginal  wall 
pulled  back.  It  is  always  well  to  use  retractors  when  packing  the 
vagina  or  cervix,  because  if  they  are  not  used,  the  gauze,  when  being 
pushed  in,  abrades  the  mucous  surface.  The  gauze  is  carefully 
pushed  in  through  the  cervix,  and  the  vagina  is  firmly  packed 
(Fig.  248).  The  plug  is  left  for  twenty-four  hours,  when,  on  removal, 
the  os  is  often  sufficiently  dilated  to  allow  of  the  ovum  being 
removed ;  indeed,  it  sometimes  comes  away  with  the  plug.  Plugging 
is  most  efficacious  when  there  are  active  uterine  contractions  going 
on.  If  uterine  activity  is  feeble,  one  may  get  very  little  dilatation 
from  the  plug. 

If,  on  removing  the  gauze,  dilatation  is  not  sufficient,  the  plugging 
may  be  repeated.  The  objection  to  this  method  is  that  it  necessitates 
repeating  the  anaesthesia,  and  involves  much  vaginal  manipulation. 
If  plugging  is  not  sufficient,  I  proceed,  therefore,  to  more  rapid 
dilatation  with  dilators  or  expanding  tents.  In  using  metal  dilators 
one  must  take  care  not  to  drag  too  hard  on  the  cervix,  which  is 
grasped  with  the  vulsellum  forceps ;  and,  indeed,  I  have  often  found 
it  better  to  push  down  the  uterus  over  the  dilator  with  the  external 
hand  rather  than  try  to  push  the  dilator  into  the  uterus.  The 
cervix  also  is  very  liable  to  be  torn  by  the  dilator,  so  that  I  prefer 


INTERRUPTED  GESTATION 


529 


the  more  gradual  method  of  dilating  with  tents.  This  tearing 
always  begins  on  the  inside.  These  matters  are  especially  referred 
to  in  Chapter  XXVIII. 

After  the  cervix  is  dilated,  the  uterus  must  be  thoroughly  ex- 
plored, to  see  how  much  of  the  ovum  is  left  behind ;  and  let  me  again 


Fig.  248.— Plugging  the  Cervix  with  Gauze.     (Bumm. 


say,  in  a  case  of  abortion,  if  there  is  the  least  doubt  of  anything 
having  been  left,  the  uterus  should  always  be  explored  with  the 
fingers.  I  do  not  favour  the  curette,  except  in  very  early  abortions. 
Apart  altogether  from  the  danger  of  the  curette  when  the  uterus  is 
soft,  as  it  is  in  pregnancy,  there  is  the  difficulty  of  removing  the 
whole  ovum  with  it,  for  it  slips  round  the  ovum,  and  merely  breaks 

34 


580 


OPERATIVE  MIDW  IFEB.Y 


it  up.     There  is  nothing  bo  good  ae  the  fingers  tor  removing  an  in- 
complete abortion.     I  frequently  run  over  the  uterine  Burface  with  ;l 

curette    after     I    have    removed    the    ovum.       The    douche    cur< 
(Fig.  •-!!!»)  is  very  suitable.     The  operation  is  carried  out  as  follows: 
Having  lixed  tlie  cervix  with   vulsellum   forceps,  the  curette   i-  'are- 


3 


■.<:i.l,.».a.v..,:K«.i.i.:,-fc^-^- 


Fig.  249      Douche  I  lorette. 

fully  passed  into  the  uterus,  until  one  feels  it  against  the  fundus. 
Long  sweeps,  from  fundus  to  cervix,  are  made,  and  the  whole  surface 
is  carefully  scraped. 

After  removing  the  remains  of  an  abortion,  it  is  always  well  to    I 
give  an  intra-uterine  douche  of  sterilized  water,  at  a  temperature  of 


Fig.  250. — Bozemann-Fritsch  Intra-uterine  Nozzle. 

118°  F.,  to  wash  away  all  debris  and  to  stimulate  the  uterus  to 
contraction.  This  is  best  done  with  a  Bozemann-Fritsch  nozzle 
(Fig.  250).  Budin's  nozzle  is  also  a  useful  form  (Fig.  251).  Great  care 
must  he  taken  that  the  water  is  not  introduced  at  too  high  a  pressure. 
I  use  an  antiseptic  douche  of  1  in  3,000  biniodide  of  mercury  only  if 


Fig.  251. — Budin's  Intra-uterine  Nozzle. 


the  uterine  contents  are  septic.  I  ma_y  here  remark  that  the  Rotunda 
siphon  douche  tube  (Fig.  252^  is  much  more  convenient  and  more 
easily  sterilized  than  a  douche  can. 

A  septic  ovum  should  always  be  removed,  if  possible,  without 
the  curette.  In  two  septic  incomplete  abortions  recently  curetted 
an  anterior  pelvic  cellulitis  followed — I  believe  as  a  result  of  the 
treatment  employed.  When  the  os  is  sufficiently  dilated  there  is  no 
difficulty  ;  the  ovum  is  removed  with  the  lingers.     When,  however, 


INTERRUPTED  GESTATION 


5:51 


the  os  is  closed  and  difficult  to  "dilate,  one  has  to  choose  between 
plugging  with  gauze,  the  insertion  of  a  sea-tangle  tent,  immediate 
dilatation  with  metal  dilators,  and  incising  the  cervix,  before  one  can 
clear  out  the  uterine  contents. 

When  a  diagnosis  of  missed  abortion  has  been  made,  the  only 
question  to  settle  is,  Should  the  uterus  be  emptied  immediately,  or 
should  one  wait  until  the  ovum  is  expelled  ?     Of  course,  there  can  be 


Fig.  252. — Rotunda  Siphon  Douche  Tube. 

no  question  of  waiting  if  there  are  any  disturbing  symptoms;  but 
even  if  there  are  not,  many  believe  in  emptying  the  uterus,  as  they 
consider  a  dead  body  in  the  uterus  is  a  constant  source  of  danger. 
Others,  however,  hold  a  different  view,  and  would  wait  until  uterine 
contractions  come  on  spontaneously.  My  own  attitude  is  to  remove 
the  ovum  if  there  is  the  slightest  discharge  or  discomfort,  and  if  the 
knowledge  of  its  presence  is  an  irritation  to  the  patient.  Otherwise 
I  leave  the  ovum  to  be  expelled  spontaneously. 


>82 


OI'EKATIYK  MII>WII'K1;Y 


Hydatidiform   Mole  (Vesicular  Mole,  Dropsy  of  Chorion,  Cystic 
Degeneration  of  Chorion,  Myxoma  of  Chorion). 

This   disease   of    the   chorion    is   a   cystic    degeneration   of    the 
terminal  villi.    It  may  occur  at  any  time  of  reproductive  life,  although 


Fig.  253. — Portion  of  Hydatidiform  Mole.     (Author's  Collection.) 

it  is  a  little  more  common  between  the  ages  of  thirty  and  forty  than 
before  or  after  these  years.  In  general  appearance  the  mole  resembles 
a  large  bunch  of  small  grapes ;  consequently  the  Germans  speak  of  it 
as  a  '  Traubenmole '  (Fig.  253).     On  examining  one  of  these  affected 


INTERRUPTED  GESTATION  533 

villi,  it  will  be  observed  that  the  villus  is  not  altered  throughout  its 
entire  course,  but  that  swellings  occur  here  and  there  along  its  wall. 

These  cysts  vary  in  size,  but  they  are  rarely  much  larger  than  a 
hazel-nut.  As  a  rule,  the  disease  attacks  the  ovum  at  an  early  period 
of  its  existence,  and  invades  the  greater  part  of  the  chorion.  In  the 
more  marked  cases  of  the  disease  early  death  of  the  embryo  occurs, 
so  that  often  no  trace  of  it  is  to  be  discovered.  In  other  cases  only  a 
small  portion  of  the  chorion  is  affected.  Should  this  be  very  slight 
in  amount,  the  general  nutrition  of  the  foetus  may  be  little  interfered 
with,  and  pregnancy  may  continue  undisturbed. 


Fig.  254. — Microscopic  Section  of  a  Portion  of  Uterine  Wall  invaded  by  the  Villus 

of  a  Hydatid  Mole. 

The  microscopic  changes  consist  in  a  destruction  of  the  stroma 
of  the  villi,  more  particularly  in  those  parts  where  the  vesicles  are 
present.  It  is  generally  stated  that  the  bloodvessels  are  also  to  a 
large  extent  obliterated.  In  the  more  marked  cases  of  the  disease, 
however,  it  is  probable  that  no  vessels  have  ever  existed;  the  villi  are 
really  nourished  from  the  maternal  tissues.  As  regards  the  epithelium 
covering  the  villi,  it  is  found  that  both  layers  undergo  proliferation 
of  a  very  irregular  character.  The  syncytium  is  very  irregularly 
developed,  and  the  nuclei  are  large  and  vesicular.  Numerous  vacuoles 
are  present  in  the  protoplasm.  Here  and  there  great  proliferation  of 
Langhan's  layer  is  observed.  All  these  features  may  be  seen  in  the 
accompanying  illustration  (Fig.  254)  from  my  third  case  of  chorion- 
epithelioma.     The  tumour  followed  a  hydatidiform  mole.     The  uterus 


534 


OPERATIVE  MIDWIFERY 


was  removed.    The  operation  was  performed  four  years  ago,  and  the 

woman  is  still  in  perfect  health. 

In  recent  years  attempts  have  heen  made  to  differentiate  what 
might  be  termed  malignanl  and  benign  forms  of  vesicular  mole. 
Observations,  however,  in  this  direction  have  heen  very  disappointing. 
There  is  no  means  of  telling  by  microscopically  examining  a  portion 
of  a  mole  removed  whether  the  proliferation  of  the  epithelium  is  ol  a 


Fig.  255.— Chorion-Epithelioma.     (Author's  Collection.) 


benign  or  malignant  character.  All  moles  are  potentially  malignant. 
The  development  of  a  chorion-epithelioma  would  appear  to  depend 
chiefly  upon  the  completeness  with  which  the  mole  is  expelled  or 
removed.  Some  moles  penetrate  the  uterine  wall  much  more  than 
others  ;  indeed,  there  are  a  few  cases  on  record — as,  for  example,  one 
by  Martin — where  rupture  of  the  uterus  occurred  through  the  mole 
penetrating  the  wall.     In  these  cases,  where  the  wall  is  much  eroded. 


INTERRUPTED  GESTATION  535 

it  is  more  difficult  to  remove  the  diseased  chorion  completely;  con- 
sequently chorion-epithelioma  is  more  likely  to  follow. 

As  regards  chorion-epithelioma,  I  need  not  remind  my  readers  that 
a  vesicular  mole  is  not  necessary  for  the  development  of  this  disease  ; 
it  may  follow  any  pregnancy.  There  are  cases — as,  for  example, 
Schlagenhaufer's1  —  where  metastatic  deposits  formed  during  preg- 
nancy, although  the  uterine  contents  were  apparently  perfectly  normal. 
I  cannot,  however,  further  discuss  here  this  most  interesting  tumour. 

Symptoms. — In  cases  where  only  a  very  small  part  of  the  chorion 
is  affected  there  are  no  symptoms,  and  pregnancy  continues  undisturbed. 
When,  however,  the  disease  is  at  all  extensive,  well-marked  and  char- 
acteristic symptoms  exist.  There  are  the  ordinary  early  subjective 
symptoms,  such  as  sickness,  pain  in  the  breasts,  and  suppression  of 
menstruation ;  in  addition  the  woman,  as  a  rule,  feels  out  of  sorts,  and 
is  often  very  anemic.  There  is  usually  great  enlargement  of  the 
uterus:  indeed,  the  must  striking  feature  is  that  the  distension  is  out  oj 
all  proportion  to  the  age  of  the  pregnancy.  In  a  case  which  was  recently 
under  my  care  the  woman  thought  herself  three  months  pregnant,  but 
when  I  examined  her,  I  found  the  fundus  two  inches  above  the  level  of 
the  umbilicus.  On  palpating  the  distended  uterus,  it  is  found  to  be 
globular  in  form  and  tensely  elastic  to  the  touch.  It  is  commonly 
stated  that  the  uterus  feels  soft  and  boggy ;  this  sensation  was  only 
experienced  in  one  of  the  six  cases  which  have  been  under  my  care. 
Pain  is  often  complained  of  over  the  uterus,  and  this  is  usually 
increased  by  pressure.  Another  striking  and  absolutely  characteristic 
symptom  is  a  sero-sanguineous  discharge,  with  some  of  the  vesicles 
floating  in  it.  This,  however,  is  not  always  present.  Not  infrequently 
the  discharge  takes  the  form  of  irregular  hemorrhages,  which  in  no 
way  differ  from  those  occurring  in  an  ordinary  abortion. 

When  the  chorion  is  extensively  affected,  abortion  usually  occurs 
about  the  fifth  or  sixth  month  ;  very  rarely  indeed  is  the  ovum  retained 
longer. 

The  hydatidiform  mole  in  its  typical  form — that  is  to  say,  where 
there  is  rapid  distension  of  the  abdomen,  and  the  characteristic 
discharge  containing  the  vesicles — is  easy  of  diagnosis  ;  but  where  the 
menstrual  history  is  vague,  and  the  discharge  is  simply  sanguineous, 
the  diagnosis  may  be  very  difficult  until  the  os  is  dilated,  the  finger 
inserted,  and  the  shaggy  chorionic  villi  felt.  Even  then,  if  the 
vesicles  do  not  come  away,  the  accoucheur  may  think  at  first  that  he 
has  to  deal  with  a  placenta  previa.  That  mistake  was  actuallj7  made 
in  one  of  my  six  cases. 

A  prognosis    in    this    disease    must    be    given    with    considerable 

1    Wien.  Klin.  Woch.,  1899,  No.  2,  p.  18. 


586  OPERATE  E  MIDWIFERY 

caution,  for  not  only  is  there  immediate  danger  of  rupture  of  the 
uterus,  haemorrhage,  and  septic  infection,  bu1  there  is  also  the  latex 
danger  of  chorion-epithelioma  (Fig.  255).  (In  my  six  cases  of 
hydatidiform  mole  two  developed  chorion-epithelioma,  while  in  my 

four  cases  of  chorion-epithelioma  the  abortion  was  only  once  a 
vesicular  mole.) 

Treatment. — Whenever  thecondition  is  recognized,  the  uterus  mast 
be  carefully  and  thoroughly  emptied.  If  the  os  is  sufficiently  dilated,  no 
difficulty  will  be  found  in  doing  this  ;  but  if  the  cervix  is  not  sufficiently 
patent,  the  cervical  and  vaginal  canals  should  be  plugged  with  sterilized 
gauze  until  there  is  sufficient  dilatation.  For  the  removal  of  the  mole 
the  fingers  should  be  employed.  It  is  of  great  importance  that  the 
uterine  cavity  should  be  thoroughly  evacuated,  as  any  portion  of  the 
mole  left  behind  may  form  the  nidus  for  a  chorion-epithelioma.  The 
most  difficult  cases  are  naturally  those  in  which  the  degenerated  villi 
penetrate  deeply  into  the  uterine  wall.  In  these  cases  great  care 
must  be  exercised  in  scraping  with  the  fingers,  as  the  uterus  may  be 
very  readily  perforated.  While  the  wall  is  being  scraped  with  the 
fingers  the  external  hand  should  steady  the  uterus,  and  should  always 
be  applied  over  the  part  that  is  being  scraped.  The  operator  who  has 
extensive  experience  of  curetting  the  uterus  may  employ  a  blunt  curette 
with  extreme  caution,  but  I  would  advise  the  general  practitioner  not 
to  employ  the  curette,  but  to  trust  entirely  to  his  fingers. 

After  removing  the  mole  a  hot  intra-uterine  douche  should  be  given, 
with  the  object  of  washing  away  all  debris  and  stimulating  the  uterus 
to  retract.  It  is  advisable  after  douching  to  go  over  the  uterine 
surface  once  again  with  the  fingers,  paying  special  attention  to  any 
areas  in  which  the  uterine  wall  has  been  deeply  eroded.  A  second 
douche  should  then  be  given. 

A  patient  from  whom  a  vesicular  mole  has  been  removed  must  be 
very  carefully  watched.  Should  any  septic  mischief  arise,  a  weak 
antiseptic  douche  should  be  given  night  and  morning  till  the  tem- 
perature subsides.  For  some  months,  too,  the  woman  must  be 
seen  at  short  intervals,  in  case  chorion -epithelioma  should  develop. 
This  will  manifest  itself  by  a  recurrence  of  hamorrhage.  Should  such 
a  condition  arise,  the  uterus  must  be  extirpated  immediately.  In 
addition  the  general  health  of  the  patient  should  be  attended  to,  and 
tonics,  especially  iron  and  strychnine,  should  be  administered.  It  is 
advisable  to  caution  the  patient  against  becoming  pregnant  until  a 
considerable  time  has  elapsed. 


CHAPTER   XXXII 

ECTOPIC  PREGNANCY— PELVIC  HEMATOCELE— PREGNANCY  IN 
RUDIMENTARY  HORN  (CORNUAL  PREGNANCY) 

In  considering  extra-uterine  pregnancy  I  shall  confine  my  remarks 
almost  entirely  to  the  clinical  and  operative  aspects  of  the  subject. 
The  etiology  and  the  minute  pathology  of  this  most  interesting 
condition  I  do  not  intend  to  discuss,  as  they  would  necessarily  take 
up  a  large  amount  of  space,  and  are  outside  the  province  of  the 
present  work.  I  must,  however,  refer  to  the  grosser  changes  which 
occur  in  the  tissues  as  a  result  of  extra-uterine  pregnancy,  so  that  I 
purpose  considering  the  subject  under  the  three  following  headings  : 
(1)  Pathological  Anatomy.     (2)  Clinical  Features.     (3)  Treatment. 

Pathological  Anatomy. 

Although  it  is  possible  for  the  ovum  to  become  implanted  anywhere 
between  the  ovary  and  uterus,  it  is  found  with  few  exceptions  that  it  is 
to  the  interior  of  the  tube  it  becomes  attached  in  the  first  instance- 
Until  recently  the  old  idea  of  '  ovarian  '  and  '  abdominal '  pregnancy 
was  doubted  by  every  one,  and  absolutely  denied  by  not  a  few.  In 
the  face  of  recently  recorded  cases  that  extreme  position  has  been 
abandoned,  and  every  one  now  admits  the  possibility,  not  only  of 
primary  ovarian,  but  even  of  primary  abdominal  pregnancy. 

With  our  increasing  knowledge  of  tubal  pregnancy,  it  has  been 
found  that  the  ovum  may  attach  itself  to  different  parts  of  the  tube, 
and  that  these  different  situations  vary  in  point  of  frequency. 

Not  only  that,  but  the  course  the  pregnancy  runs  is  very  consider- 
ably influenced  by  the  site  of  the  implantation. 

I  shall  consider  ectopic  pregnancy,  therefore,  in  the  following 
situations,  and  the  order  in  which  they  are  mentioned  is  the  order 
of  their  frequency :  (1)  Ampulla  ;  (2)  isthmus  ;  (3)  infundibulum  : 
(4)  interstitial  portion  of  the  tube ;  (5)  ovary  ;  (G)  bowel,  omentum, 
mesentery,  etc.  (primary  abdominal  pregnancy). 

537 


538  Ol'KllATIVK  MIDWIFERY 

(1)  Implantation  in  the  Ampulla. — This  is  much  the  commonest 
munition — in  all  probability  because  it  is  the  widest  part  of  the 
tube,  in  id  the  ovum  situated  then;  obtains  the  best  vascular  supply. 
Although  I  do  not  intend  to  discuss  the  microscopic  pathology  of 

ectopic  pregnancy,  I  must  refer  in  a  word  or  two  to  what  happens 
when  the  fertilized  ovum  becomes  implanted  in  the  tube.  I  shall  be 
as  brief  as  possible,  and  shall  point  out  only  the  features  that  have 
a  bearing  upon  the  subject  from  the  practical  side. 

There  is  no  specimen  of  tubal  pregnancy  so  early  as  Peters  and 
Leopold's  youngest  uterine  ovum,  but  there  have  been  several  young 
enough — especially  Filth's — to  satisfy  every  one  that  what  takes  place 
in  a  uterine  pregnancy  takes  place  also  in  an  extra-uterine.  The 
fertilized  ovum  buries  itself  in  the  wall  of  the  tube.  This  occurs  uo 
matter  whether  the  ovum  primarily  becomes  attached  to  a  crest  or  a 
trough  of  the  wavy  mucous  membrane  (so-called  columnar  and  inter- 
columnar  insertions).  It  does  this  by  means  of  its  trophoblast,  and 
illustrations  showing  this  may  be  seen  in  such  papers  as  those  of 
Berkeley  and  Bonney1  and  Fiith.2 

All  the  tissues  are  affected — muscular,  connective  tissue,  blood- 
vessels. A  decidua  capsularis  (reflexa)  is  sometimes  found,  but  in 
many  cases  the  ovum  is  so  deeply  embedded  in  the  tube  wall  that 
there  is  hardly  any  bulging  of  the  sac  into  the  lumen  of  the  tube. 
The  connective  tissue  cells  become  altered  and  take  on  the  appearance 
of  decidual  cells  to  a  varying  extent.  Sometimes  the  tube  away  from 
the  sac  and  even  the  other  tube  share  in  this  change.  There  is, 
however,  no  well-formed  decidua,  as  in  the  uterine  pregnancy.  From 
the  practical  standpoint  the  damage  done  to  the  bloodvessels  is  the 
most  important.  These  have  their  walls  eroded  by  the  trophoblast, 
just  as  occurs  in  the  uterine  vessels  in  the  formation  of  the  inter- 
villous space.  In  the  uterus  there  is  the  support  of  a  thick,  dense 
muscle  wall,  but  in  the  tube  there  is  nothing  of  this :  the  thin  sheets 
of  circular  and  longitudinal  fibres  are,  therefore,  soon  broken  up  and 
destroyed.  Sooner  or  later  the  tendency  is  for  the  ovum  to  have  its 
connexions  with  the  tube  wall  disturbed,  by  reason  of  minute  intra- 
mural hemorrhages. 

With  the  ovum  embedded  in  the  ampulla  several  terminations 
are  possible:  (a)  Tubal  abortion,  complete  or  incomplete;  (M  tubal 
rupture ;  (c)  formation  of  a  mole,  with  subsequent  changes — atrophy 
or  disintegration  of  it ;  (d)  continuance  of  the  pregnancy  to  the  later 
months  or  even  term. 

(a)  Abortion. — As  Werth  has  very  rightly  pointed  out,  this  may  be 

1  Journ.  Obst.  cmd  Oyn.  Brit.  Empire,  February,  L905. 
'-'  ArcMvf.  Qyn.,  Bd.  Ixiii.,  p.  97. 


ECTOPIC  PREGNANCY  539 

described  as  an  internal  rupture  of  the  gestation  sac,  just  as  the  second 
termination  of  rupture  of  the  tube  may  be  termed  '  external  rupture.' 
The  whole  ovum  may  be  shed  from  the  tube,  or  only  part  may  be 
separated,  when  the  abortion,  comparing  it  with  a  uterine  one,  is 
incomplete. 

With  this  termination  there  is  some  bleeding  into  the  peritoneal 
cavity,  but  it  is  seldom  great,  and  ceases  after  the  ovum  is  completely 
expelled.  When,  however,  the  abortion  is  incomplete,  a  '  drip-drop  ' 
of  blood  continues  from  the  end  of  the  tube,  and  this  blood  gradually 
accumulating,  forms  a  hematocele  more  marked  on  one  side  of  the 
pelvis,  and  often  made  up  of  blood  of  different  ages.  (Pelvic  hema- 
tocele is  considered  later,  p.  571.) 

The  tube,  after  complete  abortion,  very  soon  resumes  its  normal 
appearance,  just  as  the  uterus  does  after  expelling  its  contents 
prematurely.  Everything  then  quietens  down,  and  the  hematocele 
that  forms  in  time  disappears.  With  incomplete  abortion,  however, 
there  are  recurrences  of  abdominal  pain  and  hemorrhage,  the 
symptoms  which  we  shall  see  are  the  features  of  ectopic  pregnancy. 

(b)  Rupture  of  the  Tube. — At  one  time  this  was  considered  the 
commonest  termination,  but  it  is  now  known  to  be  less  frequent  than 
tubal  abortion.  I  have  explained  how  it  is  sometimes  termed  '  external 
rupture  '  of  the  gestation  sac.  There  is  another  variety  of  rupture, 
according  to  Berkeley  and  Bonney1 — namely,  'intramural' — which 
these  writers  compare  to  the  change  occurring  when  a  sacculated 
aneuiysm  becomes  diffuse.  In  many  cases,  no  doubt,  this  is  a  stage 
prior  to  '  internal '  and  '  external '  rupture  about  to  be  referred  to. 

When  rupture  occurs,  it  takes  place  as  a  rule  between  the  sixth 
and  tenth  weeks,  although  it  may  occur  much  earlier  than  that  date. 

The  rupture  and  accompanying  hemorrhage  may  take  place  into 
the  general  peritoneal  cavity  (intraperitoneal),  or  between  the  layers 
of  the  broad  ligament  (extraperitoneal),  for  the  tube  is  not  completely 
surrounded  by  peritoneum,  being  uncovered  along  the  lower  part  of 
its  wall,  where  the  layers  of  the  broad  ligament  come  together. 

Bupture  directly  into  the  peritoneal  cavity  is  much  the  most 
frequent  termination,  and,  as  might  be  expected,  is  the  more  serious, 
for  there  is  no  let  or  hindrance  to  the  effusion  of  blood.  With  the 
extraperitoneal,  the  layers  of  the  broad  ligament  limit  the  hemorrhage, 
although,  it  must  be  remembered  that  they  do  not  always  do  so.  I  have, 
for  example,  seen  an  effusion  of  blood  into  the  broad  ligament  so 
extensive  that  the  hematoma  extended  up  as  high  as  the  umbilicus, 
although  the  gestation  sac  was  only  two  months  old. 

Paipture  of  the  gestation  sac  may  be  sudden,  a  large  quantity  of 
1  Journ.  Obst.  and  Gyn.  Brit.  Empire,  June,  1906,  p.  446. 


540 


OPERATIVE  .MIJ)\VIli:i;V 


blood  being  poured  out  into  the  peritoneal  cavity,  and  the  patient 
becoming  profoundly  collapsed  in  a  very  few  minutes.  More 
commonly,  however,  the  rupture  is  gradual  (Fig.  '25);).  The  sac  wall 
is  eroded  by  the  cells  of  the  trophohlast,  and  later  by  the  chorionic 


Fig.  256.— Ruptured  Tubal  Pregnancy. 

The  body  below  the  tube  is  the  ovary  ;  the  body  above  is  the  ovum  turned  upwards  fiom 
where  it  was  attached  to  the  tube  ;  the  point  "f  the  probe  is  projecting  through  t lie 
rapture  in  the  tube.     (Author's  Collection.) 


villi.      In  such  cases   there   may  be  recurrent   attacks  of   bleeding, 
abdominal  pain,  and  syncope. 

When  the  whole  ovum  is  suddenly  expelled  into  the  peritoneal 
cavity,  it  usually  dies  ;  it  is  questionable  if  it  can  re-ingraft  itself  on  a 
peritoneal  surface.     Sometimes,  however,  where  the  pregnancy  has 


ECTOPIC  PREGNANCY  541 

idvanced  farther  and  the  rupture  is  gradual,  the  placenta  remains 
ittached  in  the  tube,  and  develops  there  and  in  the  surrounding 
iissues,  while  the  ovum  goes  on  growing  in  the  free  abdominal  cavity. 
For  such  an  occurrence  it  is  usually  necessary  that  the  foetal  membranes 
•emain  intact,  but  it  is  now  known  from  one  or  two  specimens  that  the 
['cetus  may  continue  to  grow,  although  its  membranes  have  ruptured. 
The  condition  is  comparable  to  what  sometimes  occurs  in  an  intra- 
uterine pregnancy  (Grossesse,  '  Extra-Membraneuse,'  p.  148).  Sooner 
or  later,  however,  the  foetus  dies  in  these  cases. 

Rupture  of  the  tube  between  the  layers  of  the  broad  ligament  is, 
as  I  have  already  said,  of  rare  occurrence.  In  fifty-four  cases  it 
occurred  in  five,  but  that  is  a  very  much  higher  proportion  than  is 
usually  found.  Here,  again,  death  of  the  ovum  usually  results,  and  a 
hematoma  forms  of  varying  size.  Later,  a  secondary  rupture  into 
the  peritoneal  cavity  may  take  place.  Quite  recently  I  had  an  example 
of  this,  where  I  enucleated  from  the  left  broad  ligament  an  ectopic 
sac,  which,  from  the  history,  had  first  ruptured  into  the  broad  ligament 
and  later  into  the  peritoneal  cavity. 

In  a  few  cases  the  growth  of  the  ovum  continues  in  the  broad 
ligament,  and  the  two  layers  become  more  and  more  separated ;  in 
fact,  many  of  the  cases  of  extra-uterine  pregnancy  which  advance  to 
the  later  months  are  of  this  variety.  The  form  is  spoken  of  by 
various  names — '  extraperitoneal,'  '  subperitoneal,'  '  pelvic,'  or  '  broad- 
ligament  '  gestation.  As  the  pregnancy  advances  the  layers  of  the 
broad  ligament  become  still  farther  separated,  the  peritoneum  becomes 
stripped  off  the  bladder  and  rectum,  and  pushed  up  by  the  enlarging 
gestation  sac,  which  displaces  all  organs  in  its  growth.  This  advanced 
variety  is  spoken  of  as  '  subperitoneal  abdominal  pregnancy.'  When 
it  has  reached  the  later  weeks  the  sac  seldom  ruptures.  If  it  should 
advance  to  term,  a  spurious  labour  occurs,  with  painful  uterine  con- 
tractions and  the  shedding  of  a  uterine  decidua.  The  fcetus  at  this 
time,  if  not  extracted  by  abdominal  section,  soon  dies.  If  retained, 
as  it  has  been  in  not  a  few  cases,  it  becomes  mummified,  altered  into 
a  lithopedion,  or  disintegrated  and  expelled  through  bowel,  abdominal 
wall,  bladder,  etc. 

(c)  Tubal  Mole. — In  this  variety  the  ovum  is  surrounded  by  layers 
of  blood-clot  (Fig.  257).  Rupture  may  arise,  or  if  it  is  retained  it 
shrivels  up,  or,  its  tissues  becoming  disintegrated,  a  hematosalpinx 
forms.  Suppurative  changes  may  even  occur  and  the  sac  become 
infected.  In  such  cases  the  patient  seldom  continues  absolutely  free 
from  symptoms  of  abdominal  discomfort ;  there  is  usually  a  dragging 
pain,  irregular  menstruation,  and  a  general  feeling  of  abdominal 
uneasiness. 


542  OPERATIVE  MIDWIFERY 

(il)  Pregnancy  may  advance  to  Full  Term  without  Rupturi  of  the 
Sac. — Such  cases  .ire  extremely  rare,  but  bhey  do  sometimes  occur. 
The  growing  sac  usually  contracts  adhesions  to  the  surrounding 
structures,  and  displaces  these  to  a  greater  or  less  extent.  But  oc 
sionally  the  sac  may  be  free,  as  in  a  most  interesting  case  described 
by  Amos,1  where  there  were  only  adhesions  in  the  neighbourhood  of 
a  small  perforation  of  the  sac  wall.  The  placenta  was  situated  at 
that  point. 

(2)  Implantation  of  the  Ovum  in  the  Isthmus  of  the  Tube. — It 
is  only  within  recent  years  that  implantation  in  the  isthmus  of  the 
tube  has  been  recognized  to  present  features  different  from  the  variety 
previously  described,  where  the  ovum  is  lodged  in  the  ampulla.    "While 


Fig.  257. — Tubal  Mole.     (Author's  Collection.) 

theoretically  the  different  terminations  already  described  for  the 
previous  form  may  also  occur  in  this  one,  it  is  found  in  practice  that 
rupture  is  peculiar!;/  frequent,  and  occurs  generally  at  a  very  early 
date — often,  indeed,  as  early  as  the  second  or  third  week — and  often 
before  any  menstrual  period  is  missed.  The  explanation  of  this 
early  rupture  is  that  the  muscular  fibres  are  peculiarly  scanty  and 
poorly  developed,  so  that  the  ovum  readily  perforates  the  tube  wall. 

(3)  Implantation  of  the  Ovum  on  the   Infundibulum.     This 
implantation  may  be  directly  on  the  infundibulum,  or  on  the  elongated 
ovarian  fimbria.     The  occurrence  is  a  very  rare  one.      The   ovum 
1  Zeit.f.  Geb.  u.  Qyn.,  Bel.  liv.,  Heft  1,  p.  169. 


ECTOPIC  PREGNANCY  543 

either  becomes  separated,  or,  contracting  adhesions  to  the  surrounding 
parts,  continues  to  develop. 

(4)  Implantation  of  the  Ovum  on  the  Interstitial  Portion  of  the 
Tube. — In  this  form  of  extra-uterine  pregnancy  the  uterus  is  found 
much  enlarged  in  one  corner.  As  giving  an  idea  of  its  rarity,  I  would 
mention  that  Werth l  states  that  in  120  operations  for  ectopic  pregnancy 
he  had  not  met  an  example  of  this  form.  Personally,  I  have  had  one 
case  in  my  series  of  fifty-four.  Subdivisions  are  sometimes  made 
of  interstitial  pregnancy — the  one  tubo-uterine,  where  the  sac  extends 
into  the  uterine  cavity,  and  the  other  utero-tubal,  where  it  extends 
into  the  tube,  and  really  is  a  variety  of  implantation  in  the  isthmus. 
In  its  typical  form  the  ovum,  attached  between  the  uterine  and 
abdominal  openings,  grows  in  the  wall  of  the  uterus  and  dissects  up 
the  muscular  layers.  The  corner  of  the  uterus  is  pushed  upwards, 
the  sac  enlarging  especially  in  that  direction.  Sooner  or  later  rupture 
takes  place,  occasionally  into  the  uterine  cavity,  but  most  commonly 
into  the  peritoneal  cavity.  It  is  attended  with  very  profuse  haemor- 
rhage, as  large  vessels  are  usually  torn.  It  is  generally  stated  that 
rupture  is  a  late  occurrence,  often  not  taking  place  until  the  fifteenth 
or  sixteenth  week,  but  from  the  following  table  given  by  Werth  2  it  will 
be  seen  that  rupture  not  infrequently  occurs  early.     Here  is  his  list : 


First  month 

...     1 

Third  to  fourth  month 

...     2 

First  to  second  month 

...     3 

Fourth  month 

...     4 

Second  month 

...     4 

Fourth  to  fifth  month 

...     4 

Second  to  third  month 

...     6 

Fifth  month 

...     3 

Third  month 

...     4 

Fifth  to  sixth  month  ... 

...     1 

The  following  is  a  brief  history  of  my  own  case  (Fig.  258) : 

Mrs.  X  was  sent  to  me  by  Dr.  Rennie,  of  Coatbridge,  on  account  of 

an  abdominal  swelling,  which  he  considered  to  be  an  ectopic  sac.  The  history 
was  as  follows  :  The  woman,  a  multipara,  was  suddenly  seized,  when  about 
seventeen  weeks  pregnant,  with  severe  abdominal  pain.  Within  a  very  short 
time  she  was  profoundly  collapsed — indeed,  so  collapsed  was  she  that  her 
doctor  did  not  think  she  could  possibly  recover.  With  restoratives  and 
transfusion,  however,  she  slowly  rallied,  and  ultimately  became  quite  well. 
When  I  saw  her  I  could  distinguish  a  swelling  elongated  vertically,  of  about 
the  size  of  an  ostrich  egg,  occupying  the  hypogastric  and  right  iliac  areas,  and 
extending  up  to  about  the  level  of  the  umbilicus.  On  bimanual  palpation 
this  swelling  was  intimately  connected  with  the  uterus.  The  uterus  could 
not  be  distinguished  from  the  swelling,  but  on  the  left  side  there  was  a  little 
knob,  from  which  the  lqft  appendages  seemed  to  run  off'.  In  writing  to 
Dr.  Rennie  I  pointed  out  to  him  that  if  the  case  was  one  of  extra-uterine 

1     Winckel's  '  Handbuch  der  Geb.,'  Bd.  ii.,  Teil  ii.,  p.  739.  -  Op.  cit. 


5  l  l 


Ol'KltATIVK  MIDWIFERY 


pregnancy,  it  must  bo  of  the  interstitial  variety.  A  few  days  later,  in  the 
Alexandria  Cottage  Hospital,  Coatbridge,  I  operated  upon  the  patient.  I 
must  here  thank  l>rs.  Etennie,  Macphail,  and  Wilson  for  their  trainable 
assistance.  ( ta  opening  the  abdomen  I  found  the  tumour  as  described,  most 
intimately  associated  and  adherent   to  the  Burrounding  intestine,.     With 


Gravid  Baa 


Uterus. 


Fig.  258. — Interstitial  Ectopic  Pregnancy.     (Author's  Collection.) 


great  difficulty  I  separated  these  adhesions,  and  then  found  the  sac.  which 
had  given  way  at  one  part,  and  through  which  a  foetal  limb  could  be  seen. 
So  intimately  was  the  sac  connected  with  the  uterus  that  I  decided  the 
easiest  course  to  pursue  would  be  to  remove  that  organ  along  with  the 
tumour.  This  I  did,  and  the  specimen  is  seen  in  the  illustration.  The 
patient,  although  very  much  collapsed  after  the  operation,  which  was  a 
prolonged  one,  made  an  uninterrupted  recovery. 


ECTOPIC  PREGNANCY 


545 


The  diagnosis  of  this  variety  of  ectopic  pregnancy  is  often  very 
difficult.  It  closely  resembles  angular  pregnancy  (p.  502),  pregnancy 
in  a  rudimentary  horn  (p.  574),  and  pregnancy  in  a  septate  uterus 
(p.  800). 

(5)  Implantation  in  the  Ovary  (Ovarian  Pregnancy). — Every 
one  now  admits  the  possibility  of  ovarian  pregnancy.  There  are 
several  well-authenticated  cases — for  example,  those  of  Kouwer  and 


Fig.  259. — Ovarian  Pregnancy.     (Author's  Case.) 
A,  Tube  ;  B,  ovary  ;  C,  ovum  projecting  from  ovary  ;  D,  rupture. 

Katherine  van  Tussenbroek,1  Thomson,2  Anning  and  Littlewood,3 
Mendes  de  Leon  and  Holleman.4  My  own  case  is  here  illustrated 
(Fig.  259).  It  is  fully  described,  along  with  an  extremely  early  ovum, 
in  a  work  entitled  '  A  Contribution  to  the  Early  Embedding  of  the 
Human  Ovum,'  by  Professor  Bryce,  of  Glasgow  University,  Dr. 
Teacher,  of  the  Pathological  Institute  of   the  Royal  Infirmary,  and 

myself. 

1  Annal.  de  Gyn.,  December,  1899. 

2  American  Gyncecoloyy,  1902,  p.  1. 

3  Lond.  Obst.  Trans.,  vol.  xliii.,  p.  14. 

4  Bev.  de  Gyn.,  June,  1902,  p.  387. 

35 


546  OPERATIVE  MIDWIFERY 

Ovarian  Pregnancy  associated  with  an  Intro-Uterine  Pregnan 
Mra  MoD — -,  a  patienl  of  Dr.  Wilson's,  of  Greenock,  came  to  Glasgow 
to  spend  the  Christmas  holidays  of  L902.  She  delayed  going  home,  however, 
on  account  of  one  or  two  attacks  of  abdominal  pain,  which  she  attributed 
to  errors  in  diet.  She  supplied  me  with  the  following  details :  Sheistwenty- 
seveu  years  of  age,  has  been  married  for  two  years,  and  has  one  child,  now 
eleven  months  old.  She  nursed  the  child  for  a  few  months,  bul  then  gave  it 
up,  as  the  supply  of  milk  was  not  sufficient.  During  the  whole  time  of 
lactation  she  menstruated  regularly.  <)n  November  20  -lie  became  unwell 
for  the  last  time,  and  as  she  had  no  period  in  December,  she  considered 
herself  pregnant.     There  was  no  sickness  or  vomiting,  however.     On  New 

Year's  Day,   1903,  she  felt  a  little  backache  and  pain  in  the  lower  part  of  the 

abdomen  ;  this  pain  was  in  the  form  of  spasms,  hut  did  not  quite  resemble 
intestinal  colic,  although  she  thought  that  was  the  cause  of  her  discomfort. 
She  had  a  second  severe  attack  of  pain  on  the  night  of  .January  8.  I  saw 
her  on  January  9,  1903,  when  I  found  her  in  bed,  with  a  pulse  of  90  and  a 
temperature  of  100'4°.  She  had  had  some  sickness  and  vomiting  during  tin- 
night  ;  there  was  no  vaginal  discharge.  On  examining  the  abdomen  it  was 
found  slightly  distended  and  rigid,  more  especially  over  the  light  iliac 
region. 

On  bimanual  examination  the  uterus  was  freely  movable,  enlarged,  ami 
pushed  forward  to  the  left  by  a  soft  elastic  swelling  behind  and  to  the  right 
of  the  uterus.  The  diagnosis  of  extra-uterine  pregnancy  was  made.  Tin- 
patient  was  removed  to  a  nursing-home.  On  January  13  I  opened  the 
abdomen.  The  operation  presented  no  great  difficulties.  On  opening  the 
abdomen  a  considerable  quantity  of  blood  welled  up ;  in  all  about  two  pints 
of  black  blood  were  removed  from  the  abdominal  cavity.  When  I  pulled  up 
the  right  appendages  I  was  expecting  simply  to  find  a  ruptured  tube.  I  was 
surprised  to  find  the  tube  was  quite  free  and  undisturbed,  and  had  no  blood- 
clot  attached  to  it;  indeed,  to  the  naked  eye  it  appeared  perfectly  normal. 
On  looking  at  the  ovary,  however,  the  thought  of  ovarian  pregnancy  at  once 
occurred  to  me,  for  projecting  from  the  inner  margin  of  the  ovary  was  a 
hemorrhagic  mass  about  the  size  of  a  walnut.  With  great  care  I  removed 
the  tube  and  ovary,  and  placed  the  specimen  in  a  weak  solution  of  formalin. 
The  completion  of  the  operation  presented  nothing  of  note  ;  all  blood-clot  was 
carefully  removed,  and  the  abdominal  wound  closed  in  layers.  The  uterus 
was  unusually  large  and  soft;  I  was  very  suspicious  that  there  existed  also 
a  uterine  pregnancy,  and  I  informed  the  husband  of  this.  The  recovery  of 
the  patient  was  absolutely  uneventful,  and  she  returned  home  in  about  four 
weeks.  On  the  274th  day  from  the  first  day  of  the  last  menstrual  period  — 
viz.,  August  19 — the  patient  gave  birth  to  a  full-time  healthy  child,  so  that 
my  surmise  that  the  uterus  was  pregnant  at  the  time  of  the  operation  turned 
out  to  be  correct,  and  I  had,  therefore,  the  unique  example  of  a  coexisting 
ovarian  and  uterine  pregnancy,  the  latter  being  undisturbed  by  the  removal 
of  the  sac  of  the  former. 


ECTOPIC  PREGNANCY  547 

In  the  specimens  of  ovarian  pregnancy  which  have  been  described 
within  the  last  few  years,  rupture  has  occurred  at  a  comparatively 
early  date.  In  my  case  it  occurred  about  the  fifth  week.  Some  of 
the  other  specimens,  however,  are  older.  A  specially  interesting  one 
is  that  described  by  Menge,1  an  ovarian  pregnancy  of  nearly  full  time, 
with  a  coexisting  uterine  pregnancy.  The  diagnosis  of  a  tumour 
obstructing  labour  was  made.  When  the  tumour  was  opened  it  was 
found  to  contain  a  fully-developed  living  foetus. 

In  regard  to  ovarian  pregnancy,  round  which  so  much  discussion 
has  taken  place  in  recent  years,  it  has  been  generally  admitted  that 
the  following  conditions,  laid  down  by  Spiegelberg,  must  be  fulfilled 
before  an  ectopic  pregnancy  can  be  pronounced  truly  ovarian  : 

(1)  Absence  of  ovary  of  corresponding  side ;  (2)  elements  of 
ovarian  tissue  in  the  wall  of  the  sac  ;  (3)  attachment  of  the  sac  to  the 
uterus  by  the  ovarian  ligament ;  (4)  no  part  taken  in  the  formation  of 
the  sac  by  the  tube,  and  a  topographical  relationship  similar  to  that 
found  in  large  ovarian  tumours.  Lawson  Tait,2  always  a  sceptic  as 
regards  ovarian  pregnancy,  wrote  :  '  The  uterus  and  both  tubes  would 
have  to  be  recorded  as  intact,  and  we  should  have  one  ovary  present 
and  the  other  not  to  be  accounted  for,  save  by  its  existence  on  the 
cyst  of  the  ovum  ;  and  in  the  cyst  wall  of  such  a  case  microscopic 
evidence  of  the  presence  of  the  ovarian  tissues  would  be  required.' 

Primary  Abdominal  Pregnancy. — When  one  excludes  all  the 
older  cases  of  so-called  abdominal  pregnancy,  most  of  which  are 
examples  of  secondary  abdominal  pregnancy,  or  primary  implantation 
on  the  ovarian  fimbria,  there  are  very  few  cases  indeed  in  which  one 
can  say  the  ovum  was  primarily  attached  to  the  peritoneum.  Par- 
ticularly difficult  is  this  if  one  admits  the  possibility  of  a  tube  aborting 
or  even  rupturing,  and  the  expelled  ovum  re-ingrafting  itself  upon  the 
peritoneum  and  then  developing. 

Amongst  the  most  interesting  cases  recorded  is  that  of  Galabin,3 
whose  specimen  was  carefully  examined  by  a  committee  of  the 
Obstetrical  Society  of  London.  In  that  case  the  only  thing  against 
its  being  an  example  of  primary  abdominal  pregnancy  was  the  possi- 
bility of  its  being  a  tubal  abortion,  where  the  ovum  had  re-ingrafted 
itself  on  the  peritoneum  and  then  developed. 

The  committee  favoured  the  idea  that  the  case  was  a  genuine  one 
of  abdominal  pregnancy.  Of  course,  the  possibility  of  re-implantation 
could  not  be  excluded  ;  that  will  never  be  possible  until  it  has  been 
proved  that  an  ovum  cannot  be  detached  and  re-ingraft  itself  elsewhere. 

1  Munch.  Med.  Woch.,  1907,  p.  2452. 

2  '  Diseases  of  Women,'  1889,  vol  i.,  p.  444. 

3  Trans.  Lond.  Soc,  vol.  xxxviii.,  p.  88. 


548 


OPERATIVE  MIDWIFERY 


\  incenzo1  recently  reported  a  case  where  the  sac  was  quite  free,  and 
felt  like  an  ovarian  cyst.  Tpon  opening  the  ahdomen  the  sue  had 
adhesions  only  to  the  bowel  and  omentum.  The  uterus  and  append- 
ages were  normal  in  appearance  and  position,  and  the  sac  had  no 
connexion  with  them. 

Changes  in  the  Uterus  and  Surrounding-  Tissues  as  the 
Result  of  Ectopic  Pregnancy.— As  a  result  of  extra-uterine  preg- 
nancy the  uterus  becomes  altered  in  size,   shape,  and  consistency. 


r« 


■   f. 


A 


rl+ 


Fig.  260.  —Ruptured  Tubal  Pregnancy,  with  Decidual  Formation  in  Uterus. 
(Hunterian  Museum,  R.  R.  376,  Teacher's  Catalogue,  vol.  ii..  p.  757.) 

At  first  the  ectopic  sac  is  too  small  to  affect  the  position,  but 
later  the  uterus  may  be  displaced  forwards,  backwards,  or  to  the 
side.  It  is  also  displaced  upwards,  but  downwards  hardly  ever, 
for  even  with  a  large  sac,  such  as  a  pregnancy  that  advances  to  the 
later  weeks,  the  uterus  is  dragged  up,  not  pushed  down.  In  size 
it  steadily  increases,  sometimes  as  much  as  one  or  two  inches.  In 
shape  also  it  becomes  slightly  more  globular,  and  in  consistency 
softer.  These  two  latter  features,  however,  are  not  uniformly 
prominent. 


1  Gynecologia,  1905,  fasc  6;  ref.  Zcnt.  f.  Gyn.,  1906,  p.  412. 


ECTOPIC  PREGNANCY 


J49 


Apart  from  the  increase  in  size,  the  most  striking  change  occurring 
in  the  uterus  is  the  alteration  of  its  mucous  membrane  into  a  decidua 
{Fig.  2G0).     The  formation  of  this  decidua  takes  some  little  time,  so 


Fig.  261. — Uterine  Decidual  Cast  from  a  Case  of  Ectopic  Pregnancy. 
(Author's  Collection.) 

that  in  those  rare  cases  in  which  rupture  of  the  tube  occurs  in  the 
early  weeks,  a  properly-formed  decidua  may  not  exist.     Both  macro- 

PWF^-^I'  '■■  ■■'■ 

■VI'.  '  I'.'  1      f\  <■  '■'■J1''  I''  '■•''  v' 


fa.    } 


i       "tn^j  M-'-::.yy\ .'■■:■  ^■■>.,,.^.:  ■■■■■■    ■ 


'>i'V'S 

W 


.  '■."    i't  ;■  %■""■  K> "  •  /''•-  'si-      "' '<:'. ■?■''• 


•• 


Fig.  262. — Uterine  Decidua  in  a  Case  of  Uterine  Abortion.     (Teacher.) 

scopically  (Fig.  261)  and  microscopically  the  decidua  of  extra-uterine 
pregnancy  resembles  the  decidua  that  forms  in  the  uterus  in  an 
ordinary  pregnancy. 


550 


Ol'KKATIYE   MIDWIFERY 


\  stratum  compactum  and  spongiosum  can  be  distinguished,  tin- 
glands  in  the  deeper  part  may  he  observed  compressed  and  oblique, 
and  the  epithelial  cells  flattened  (Figs.  262  and  268).  The  whole 
interglandular  stroma  becomes  oedematous,  and  the  typical  decidual 
cells  are  everywhere  evident.  The  shedding  of  the  decidua,  which  ifl 
generally  stated  to  be  so  characteristic  a  feature  of  ectopic  pregnancy. 
is  not  by  any  means  constantly  observed.     It  usually  takes  place  at 


%sm 


Fig.  263. — Uterine  Decidua  in  a  Case  of  Ectopic  Pregnancy.     (Teacher.) 

the  time  the  tube  ruptures  or  aborts.  Very  generally  it  comes  away 
entire  ;  and  once  shed,  no  new  one  forms,  should  by  any  chance  the 
pregnancy  continue. 

It  need  hardly  be  mentioned  that  the  enlarging  sac  disturbs  the 
relationship  of  all  the  surrounding  structures. 


Clinical  Features. 

Having  considered  the  macroscopic  appearances  of  the  tissues 
affected  in  ectopic  pregnancy,  it  would  be  very  satisfactory  if,  under 
the  present  heading  of  clinical  features,  I  could  present  to  my  readers 
simple  pictures  of  the  symptomatology  of  each  of  the  varieties 
which  have  been  described.  Many  writers  have  attempted  to  do 
this.  I  have  always  felt,  however,  that  while  that  was  a  thoroughly 
scientific  method  of  approaching  the  subject  of  symptomatology,  it  led 
to  confusion  in  the  reader's  mind,  unless  he  was  very  familiar  with 
ectopic  pregnancy  and  had  encountered  examples  of  the  complication 
in  practice. 

I  will  leave,  therefore,  what  I  have  already  written  as  a  separate 
entity,  and  try  now  to  present  ectopic  pregnancy  as  one  sees  it  in 
practice  at  the  bedside.     It  is  very  interesting  when  the  operator  has 


ECTOPIC  PEEGNANCY  551 

removed  the  sac  to  know  where  the  latter  was  situated,  whether  it  was 
a  tubal  abortion  or  a  tubal  rupture,  and  whether  the  rupture  occurred 
into  the  layers  of  the  broad  ligament,  or  into  the  general  peritoneal 
cavity ;  but  such  questions  have  really  no  practical  bearing  on  the 
treatment,  and  cannot  be  more  than  suspected  until  the  abdomen  is 
opened. 

As  far  as  my  personal  experience  of  this  condition  goes,  I  would 
say  that  cases  of  ectopic  pregnancy  may  be  placed,  at  the  bedside,  in 
the  four  following  groups  : 

(1)  The  woman  is  struck  down  suddenly  with  abdominal  pain  and 
profound  collapse. 

(2)  The  woman  suffers  for  some  time  from  abdominal  uneasiness, 
pain,  occasional  faintings,  and  hemorrhagic  vaginal  discharge. 

(3)  The  woman  advances  in  her  pregnancy  to  the  later  weeks. 

(4)  The  woman  suffers  from  a  pelvic  hematocele. 

The  cases  belonging  to  Group  2  are  the  most  important,  and  very 
much  the  most  numerous ;  they,  however,  are  often  overlooked  until 
they  pass  into  Group  1,  or  very  occasionally  into  Group  3.  Group  4 
always  passes  through  1  or  2. 

(1)  The  woman  is  struck  down  suddenly  with  abdominal  pain 
and  profound  collapse.  This  type  of  acute  tubal  rupture  is  by  no 
means  common.  It  is  seen  in  its  most  typical  form  when  the  ovum  is 
in  the  isthmus  of  the  tube,  although  it  may  also  occur  even  when  the 
situation  is  the  ampulla.  If  one  questions  the  patient  regarding 
menstruation,  there  may  or  may  not  be  the  history  of  a  period  missed. 
It  all  depends  upon  the  age  of  the  pregnancy,  and  what  might 
be  termed  the  '  malignancy  of  the  ovum.'  There  are  no  premonitory 
attacks  of  abdominal  pain  or  sanguineous  vaginal  discharge ;  the 
woman  is  perfectly  well  one  minute,  and  is  suddenly  seized  with 
abdominal  pain,  the  feeling  of  something  giving  way,  and  then 
collapses.     Here  is  a  case  : 

A  young  married  lady,  aged  twenty-five,  the  mother  of  one  child,  born 
three  years  previously,  was  seized  one  afternoon,  while  going  about  her 
ordinary  household  duties,  with  severe  abdominal  pain  ;  she  fainted  and  fell. 
The  housemaid,  who  happened  to  be  on  the  same  landing,  heard  her  fall  and 
rushed  into  the  bedroom.  With  considerable  difficulty  she  lifted  her  mistress 
on  to  the  bed,  and  immediately  sent  for  a  doctor.  The  doctor,  on  his  arrival, 
fifteen  minutes  later,  found  the  patient  conscious,  but  very  pale,  and  with  a 
small  thready  pulse  of  about  150  or  160.  Appreciating  fully  the  gravity  of  the 
condition,  he  called  in  a  surgeon.  When  they  questioned  the  patient,  there 
was  no  history  of  any  previous  illness,  and  there  had  been  no  menstrual 
period  missed.  Both,  however,  were  convinced  that  some  abdominal  viscus 
had  given  way,  and  they  decided  that  the  abdomen  must  be  opened.     This 


552  OPERATIVE  MIDWIFERY 

was  done  as  soon  as  preparations  could  be  made.  The  upper  part  of  t lie 
abdomen  was  explored  first,  but  nothing  abnormal  could  be  detected  there. 
The  operator  then  passed  his  hand  down  into  the  pelvis,  and  immediately 
blood  welled  up.  The  nature  of  the  condition  was  then  apparent— an  early 
tubal  pregnancy  had  ruptured.  The  tube  was  removed,  and  ;i  rupture  was  dis- 
covered in  tlie  isthmus  close  by  the  uterus. 

The  history  is  so  striking  in  this  type  of  case  that  there  should 
never  he  any  difficulty  in  coming  to  a  diagnosis.  The  diagnosis,  how- 
ever, must  he  based  upon  the  history  and  appearance  of  the  patient, 
for  in  these  cases  of  early  rupture  nothing  may  he  felt  on  hiinanual 
examination.  The  tube  which  has  ruptured  is  soft  and  collapsed,  and 
the  blood  which  is  poured  into  the  abdominal  cavity  may  take  some 
time  to  make  itself  distinctly  felt  as  an  effusion  in  the  pouch  of 
Douglas.  Later  the  blood  collects,  and  is  felt  behind  and  around  the 
uterus  as  a  pelvic  hematocele. 

The  conditions  which  simulate  this  variety  of  what  may  be  called 
'  acute  '  or  '  fulminating  tubal  rupture  '  are  :  (a)  rupture  of  a  gastric 
or  duodenal  ulcer;  (6)  a  fulminating  appendicitis;  (c)  torsion  of  a 
pedunculated  tumour,  most  generally  of  the  ovary.  In  none  of  these 
conditions,  however,  is  the  collapse  so  profound  or  so  rapid.  There 
may  be  faintings,  which  blanch  the  face  and  disturb  the  pulse,  but 
whenever  these  pass  off  there  is  recovery  for  a  time,  followed,  of 
course,  by  progressive  abdominal  symptoms.  In  the  case  of  a  perfor- 
ating gastric  ulcer  there  may  be  a  history  of  old-standing  disturbance, 
and  in  palpating  over  that  region  there  is  tenderness  and  rigidity. 
(Confusion  arises  sometimes  from  the  fact  that  occasionally  in  cases 
of  acute  rupture  of  a  tube  the  pain  is  referred  to  the  upper  part  of 
the  abdomen.)  With  a  fulminating  appendicitis  there  will  always  be 
tenderness  and  rigidity  over  the  region  of  the  appendix.  I  need  not 
remind  my  readers  that  the  pain  following  a  ruptured  duodenal  ulcer 
is  sometimes  referred  to  the  region  of  the  appendix. 

The  third  condition  which  may  simulate  a  sudden  rupture  of  the 
tube  is  torsion  of  the  pedicle  of  an  ovarian  cyst.  The  resemblance 
becomes  marked  if,  in  addition  to  the  severe  pain  complained  of,  there 
is  a  hemorrhagic  discharge.  This  is  not  uncommon  with  a  twisted 
pedicle.  Should  the  case  be  seen  shortly  after  the  attack  of  pain  and 
collapse,  the  diagnosis  will  be  easy  if  a  distinct  tumour  is  felt  from  the 
vagina.  With  intraperitoneal  hemorrhages  no  tumour  (hematocele) 
is  felt,  for,  as  I  have  said,  the  effusion  of  blood  takes  some  time  to 
collect  and  coagulate.  With  an  ovarian  tumour,  on  the  other  hand, 
if  the  tumour  projects  into  the  pelvis  it  can  always  be  felt.  When, 
however,  it  does  not  project  into  the  pelvis  it  may  be  difficult  to  define, 
as  the  abdomen  is  so  rigid. 


ECTOPIC  PREGNANCY  558 

I  do  not  purpose  taking  up  any  longer  time  with  this  type  of  case, 
for  there  is  really  no  danger  of  its  being  overlooked  ;  the  woman  is 
so  ill  that  operative  interference  is  obviously  necessary. 

Naturally,  mistakes  in  exact  diagnosis  are  most  often  made  by  the 
general  surgeon,  who  not  infrequently  loses  a  little  time  in  searching  for 
the  mischief  in  the  region  of  the  stomach  or  duodenum,  because  he  most 
frequently  meets  with  these  cases.  Should  he  approach  the  appendix 
first  of  all,  no  time  will  really  be  lost,  because  he  will  find  the  effusion 
of  blood  whenever  he  passes  his  fingers  down  towards  the  pelvis. 

(2)  The  woman  suffers  for  some  time  from  abdominal  uneasi- 
ness, pain,  and  occasional  faintings  and  haemorrhage  vaginal 
discharge.  This  type  is  much  the  most  common.  I  may  mention 
that  all  except  two  of  my  fifty-four  cases  presented  at  one  time  the 
clinical  features  of  this  group.  Some  of  them  had  passed  into  the 
first  group  and  one  into  the  third  before  I  saw  them,  but  all  of  them 
except  two  had  premonitory  symptoms  for  some  time  before  the 
severe  collapse.  It  is  of  the  greatest  importance  that  the  medical 
practitioner  appreciates  this,  and  remembers  that  the  subjects  of 
ectopic  pregnancy  are  not,  as  a  rule,  struck  down  suddenly  without 
warning,  but  that  they  have  premonitory  symptoms  or  warnings, 
generally  of  so  marked  a  character  as  to  cause  them  to  call  in  medical 
assistance.  I  feel  sure  this  is  not  fully  appreciated.  Most  practitioners, 
if  they  think  of  ectopic  pregnancy,  picture  a  woman  suddenly  pros- 
trated by  internal  hemorrhage.  Certainly  such  cases  occur,  as  we 
have  seen,  but  they  are  very  much  the  exception.  Anyone  can 
recognize  them,  for  the  extreme  collapse  is  apparent,  but  for  the  full 
appreciation  of  those  of  the  group  we  are  now  to  consider,  a  knowledge 
of  the  condition  and  an  alert  and  judicial  mind  are  necessary. 

In  this  group  of  cases  of  the  very  first  importance  is  the  clinical 
history.  In  no  disease  that  I  know  of  is  a  careful  consideration  of  the 
history  more  important  than  in  ectopic  pregnancy.  To  illustrate  my 
point  that  there  are  usually  abdominal  disturbances  and  discomforts 
for  some  time  before  the  collapse,  let  me  give  notes  of  a  few  of  the 
cases  which  have  been  under  my  care  in  recent  years. 

CASE  I. — Seen  in  consultation  with  Dr.  B ■  and   Dr.   D ,   of   a 

neighbouring  town.  Patient  blanched,  pulse  140.  Swelling  of  lower  part 
of  abdomen,  extending  on  right  side  to  the  level  of  the  crest  of  the  ileum. 
On  bimanual  examination  pouch  of  Douglas  filled  with  hematocele  ;  uterus 
pushed  forwards  and  upwards.     Diagnosis  :  Ruptured  ectopic  pregnancy. 

The  following  history  was  obtained  :  Patient  is  thirty-seven,  has  had  four 
children,  last  four  years  ago.  No  miscarriages.  Last  menstrual  period  ended 
on  October  17.  Remained  well  until  November  15,  when  she  was  seized 
with  a  violent  shivering.     Fortnight  later  (November  30)  seized  with  severe 


554  OPERATIVE  MII>Wll-i:i;Y 

'cramps'  in  left  iliac  region.  Seven  days  later  (December  7)  seized  with 
similar  attacks,  followed  by  faintness.  Sanguineous  paginal  discharge  firel 
appeared  on  December  I  I,  when  there  was  aunt  her  attack  of  abdominal  pain. 
At  this  time  a  tender  abdominal  swelling  was  detected  in  the  ovarian  region 
by  her  medical  attendant.  Twelve  days  later  (December  22)  another  Bevi 
attack  of  abdominal  pain,  followed  by  profound  collapse.  I  saw  patient  two 
•  lays  later  ( I  December  24). 

Abdominal  section  was  performed  in  patient's  house.  A  large  quantity 
of  blood  and  the  ruptured  right  tube,  were  removed.  With  Btimulants  and 
transfusion  patient  rallied,  and  ultimately  made  a  complete  recovery. 

Cask  II. — A  young  married  lady,  the  mother  of  two  children,  was  placed 

in  a  nursing-home  under  my  care.     She  was  sent  to  me  by  l>r.  It ,  ol 

neighbouring  town,  who  diagnosed  the  condition  as  a  ruptured  ectopic 
pregnancy.  She  had  been  seized  the  previous  day  by  a  severe  attack  of 
abdominal  pain  and  collapse.  Upon  bimanual  examination  I  discovered  a 
diffuse  swelling  behind  and  to  the  right  of  the  uterus,  which  was  pushed 
forward. 

Upon  inquiry  I  discovered  that  the  patient  was  about  three  months 
pregnant,  but  that  she  had  had  several  attacks  of  abdominal  pain  for  some 
four  weeks  previous  to  the  severe  one  which  ended  in  collapse  and  caused 
her  to  be  sent  to  Glasgow  for  operation.  A  sanguineous  vaginal  discharge 
appeared  after  the  severe  attack  of  abdominal  pain,  and  a  decidua  was 
expelled  the  day  before  she  came  under  my  care. 

When  I  opened  the  abdomen,  I  discovered  a  ruptured  ampullarv  preg- 
nancy, with  a  very  considerable  amount  of  free  blood  in  the  peritoneum.  1 
removed  the  tube  and  blood-clot.     The  patient  made  an  excellent  recovery. 

Case  III. — Mrs.  C ,  aged  forty  years,  7-para,  was  admitted  into  the 

Western  Infirmary,  under  my  care,  complaining  of  pain  in  left  iliac  region, 
and  hemorrhagic  vaginal  discharge  of  six  weeks'  duration.  A  swelling] 
about  the  size  of  a  goose's  egg,  could  be  felt  in  left  broad  ligament, 
displacing  the  uterus  over  to  the  right.  From  the  history  and  bimanual 
examination  a  diagnosis  of  a  tubal  pregnancy,  which  had  ruptured  into  the 
broad  ligament,  was  made.  The  following  history  was  obtained  :  Patient 
altered  last  about  the  end  of  May.  Seven  weeks  later  she  was  seized  with 
irregular  abdominal  pains.  At  irregular  intervals  these  attacks  recurred, 
and  were  associated  with  feelings  of  faintness.  A  fortnight  before  admission 
she  was  seized  with  a  specially  severe  attack,  which  was  followed  by  collapse. 
A  vaginal  discharge  appeared  then  for  the  first  time. 

An  ectopic  sac  was  removed  from  the  left  broad  ligament.  The  recovery 
of  the  patient  was  uninterrupted. 

Case  IV. — Mrs.  I) ,  aged  thirty-six,   11 -para,  was  admitted  to  the 

Maternity  Hospital  under  my  care,  complaining  of  abdominal  pains  and 
vaginal  discharge.  I  had  seen  her  earlier  in  the  day,  and  from  the  history, 
and  the  fact  that  there  was  an  indefinite  swelling,  about  the  size  of  a  hen  - 
egg,  behind  and  to  the  right  of  the  uterus,  I  diagnosed  ectopic  pregnancy. 
and  sent  her  into  the  Maternity  Hospital. 


ECTOPIC  PREGNANCY  555 

The  history  obtained  was  as  follows':  Her  last  child  was  born  eighteen 
months  previously.  Menstruation  reappeared,  and  was  perfectly  regular 
until  September  1,  when  she  had  her  last  period.  The  period  lasted  from 
September  1  to  4.  On  October  24  abdominal  pain  began,  and  lasted  more 
or  less  for  twenty-four  hours.  Two  days  later  a  hemorrhagic  vaginal 
discharge  appeared.  The  discharge  was  not  abundant,  and  consisted  chiefly 
of  dark  clots.  There  followed  a  brownish-black  discharge,  which  continued 
until  patient's  admission.  From  October  26  to  November  G  patient  had 
several  severe  attacks  of  pain  and  faintings.  She  was  treated  with  poultices 
for  inflammation  of  the  womb.  On  opening  the  abdomen  the  right  tube  was 
found  ruptured.  There  was  a  fair  quantity  of  blood  free  in  the  abdomen 
and  surrounding  the  tube  (para-tubal  hematocele).  The  gravid  tube  and 
blood  were  removed.     Recovery  was  excellent. 

Case  V. — Mrs.  D was  seen  by  me  one  evening  in  May,  1906,  in 

consultation  with  Dr.  N .     She  was  in  a  collapsed  condition. 

The  history  of  the  case  was  as  follows :  She  had  always  been  delicate, 
and  had  one  child  seven  years  before.  Six  weeks  after  a  missed  period  she 
began  to  complain  of  abdominal  discomfort,  especially  marked  in  the  left  iliac- 
region,  and  referred  to  the  region  of  the  colon.  The  pain  was  irregular,  and 
after  about  ten  days  was  associated  with  a  slight  brownish  vaginal  discharge. 
After  a  severe  attack  of  pain  an  abdominal  examination  under  chloroform 
was  decided  upon,  but  before  it  could  be  made  another  attack  occurred, 
followed  by  profound  collapse.  An  elastic  swelling  could  then  be  felt  behind 
and  to  the  left  of  the  uterus.  So  collapsed  was  the  patient  that  the  opera- 
tion was  delayed  until  a  fortnight  later,  when  a  ruptured  gravid  tube  was 
removed.  It  was  encysted  and  closely  adherent  to  the  intestines.  The 
decidual  cast  was  shed  a  few  days  before  operation.  The  patient  made  an 
excellent  recovery. 

It  is  at  once  apparent,  from  a  consideration  of  the  cases  described, 
that  each  of  them  conforms  to  a  certain  type — period  of  amenorrhea, 
recurrent  attacks  of  abdominal  pain  and  uneasiness,  hemorrhagic 
vaginal  discharge,  and  feelings  of  faintness.  But  while  the  picture  is  so 
realistic,  and  can  be  so  readily  interpreted  after  the  abdomen  is  opened 
and  the  sac  removed,  it  is  often  a  little  difficult  to  fully  appreciate  the 
significance  and  gravity  of  the  symptoms  at  the  patient's  bedside. 
The  hemorrhage  is  apt  to  be  attributed  to  a  threatening  abortion,  and 
the  pain  to  intestinal  colic. 

Let  us  consider  these  symptoms  seriatim,  and  first  abdominal  pain 
and  uneasiness. 

The  pain  is  caused  by  the  intramural  hemorrhages  which  I  have 
described  as  so  constantly  occurring.  It  is  also  due,  no  doubt,  to 
a  colic  in  the  tube,  and  sometimes  in  the  uterus.  Naturally,  if  the 
pregnancy  advances,  the  muscular  fibres  become  destroyed,  and 
spasmodic  contraction  of  the  tube  becomes  almost  impossible.    Later, 


556  OPERATIVE  MIDWIFERY 

when  blood  has  been  effused  into  the  peritoneal  cavity,  tin:  pain  is  due 
in  part  to  irritation  of  the  peritoneum. 

The  importance  of  abdominal  pain  cannot  be  too  strongly  empha- 
sized; it  is  always  a  symptom  that  should  arrest  attention.  In  the 
case  of  ectopic  pregnancy,  it  is  generally  situated  low  down  in  the 
abdomen,  and  very  often  is  more  marked  on  one  side,  although  it  may 
extend  over  the  whole  lower  quadrant  of  the  abdomen.  Very  generally 
it  is  of  a  common  aching,  with  more  or  less  severe  exacerbations. 
Along  with  the  pain  there  is  also  rigidity  more  marked  on  the  affected 
side.  Pressure,  however,  does  not  relieve  this  pain  .is  ii  docs  an 
intestinal  colic.  Another  point  of  difference  between  tubal  and  intes- 
tinal colic  is  that  the  abdominal  uneasiness  continues  with  tubal 
pregnancy,  whereas  with  intestinal  colic  the  woman  feels  perfectly 
well  whenever  the  spasm  passes  off. 

In  some  cases,  especially  if  the  sac  is  on  the  left  side,  the  pain  is 
specially  referred  to  the  bowel.  When  there  is  constipation,  as  is  the 
case  so  often,  there  is  considerable  excuse  for  the  medical  attendant 
considering  the  pain  as  due  to  irritation  and  colic  of  the  bowel.  Later, 
if  there  is  a  large  effusion  of  blood  in  Douglas'  pouch,  great  un- 
easiness in  the  rectum,  with  a  frequent  inclination  to  go  to  stool,  is 
often  complained  of.  I  shall  refer  to  this  again  in  speaking  of  pelvic 
hematocele. 

In  the  cases  that  I  have  detailed  it  will  be  seen  that  the  patients 
had  severe  attacks  of  pain,  with  intervals  in  which  there  was  only  a 
little  abdominal  uneasiness.  It  is,  of  course,  entirely  a  matter  of 
accident  how  frequent  these  attacks  of  pain  are,  or  how  many  occur 
before  rupture  or  tubal  abortion. 

Amenorrhcea,  the  next  symptom  of  importance,  is  usually  present 
in  cases  of  this  group,  although  occasionally  the  abdominal  pain  and 
uneasiness  may  come  on  before  there  is  time  for  a  menstrual  period  to 
be  missed.  Again,  the  symptom  may  not  be  available  if  tubal  preg- 
nancy occurs  during  lactation,  or  wdien  there  is  some  pathological 
condition  associated  w7ith  amenorrhcea,  such  as  anasmia  or  chlorosis. 
The  number  of  periods  missed  varies;  but  in  the  cases  here  described — 
and  I  find  my  own  cases  are  very  similar  to  those  described  by  others — 
the  abdominal  pain  and  discomfort  come  on  before  the  second  period  ; 
that  is  to  say,  one  period  is  missed  before  symptoms  present  them- 
selves. In  only  five  of  my  cases  was  the  abdominal  pain  delayed 
until  after  the  second  missed  period. 

Naturally,  amenorrhcea  is  a  symptom  of  very  great  importance, 
for  it  at  once  directs  the  attention  of  the  physician  to  pregnancy, 
and  in  association  with  abdominal  pain  to  some  complication  of 
pregnancy. 


ECTOPIC  PEEGNANCY  557 

It  sometimes  happens  that  the  next  symptom,  hemorrhagic  vaginal 
discharge,  may  lead  to  confusion,  and  may  be  mistaken  for  a  men- 
strual period,  particularly  if  the  discharge  comes  on  at  or  about  the 
time  a  menstrual  period  is  expected  or  would  have  occurred  had 
pregnancy  not  existed.  If,  however,  this  symptom  is  inquired  into,  it 
will  usually  be  found  that  the  hemorrhagic  discharge  has  been  pre- 
ceded by  abdominal  pain  and  discomfort,  that  it  is  irregular  in  its 
time  of  appearance,  and  that  it  is  seldom  very  abundant.  The  quantity 
is  very  rarely  profuse ;  I  have  only  once  seen  it  so.  On  the  other 
hand,  it  is  very  generally  preceded  by  one  or  more  attacks  of  abdominal 
pain  and  discomfort.  Taking  the  five  cases  I  have  given  in  illustration 
of  this  group,  it  will  be  found  that  in  Case  I.  it  occurred  four  weeks 
after  the  first  attack  of  pain ;  in  Case  II.  it  occurred  four  weeks  after 
the  first  attack  of  pain ;  in  Case  III.  two  weeks  after  the  first  attack 
of  pain ;  in  Case  IV.  two  days  after  the  first  attack  of  pain ;  and  in 
Case  V.  ten  days  after  the  first  attack  of  pain. 

In  80  per  cent,  of  my  cases  the  pain  has  preceded  the  haemorrhage. 
That,  however,  is  not  the  experience  of  all  writers.  Bell,1  in  his 
analysis  of  eighty-eight  cases  treated  in  St.  Thomas's  Hospital,  gives 
a  definite  statement  regarding  this  point  in  sixty-eight  cases.  From 
an  examination  of  his  table,  it  will  be  found  that  pain  was  the  first 
symptom  in  58  per  cent,  and  haemorrhage  in  41  per  cent. 

Very  often  the  discharge  is  attributed  to  a  threatened  abortion, 
especially  if  one  or  two  periods  have  been  missed.  The  differential 
diagnosis  between  these  conditions  is  fully  considered  later. 

The  fourth  feature  of  cases  belonging  to  this  group  is  occasional 
feelings  of  faintness,  nausea,  and  sickness,  amounting  sometimes  even 
to  syncope.  It  is  due  to  reflex  irritation  of  the  peritoneum,  to  the 
intramural  haemorrhages  which  tensely  distend  the  sac  wall,  and  to 
tubal  colic.  It  may  be  said  that  the  faintness  is  due  to  haemorrhage, 
and,  of  course,  that  is  so  if  the  amount  of  haemorrhage  is  abundant ; 
but  I  have  operated  upon  many  cases  in  which  there  had  been  a 
distinct  syncope,  and  yet  the  internal  bleeding  was  very  slight,  and, 
yer  se,  could  not  have  produced  the  collapse.  Besides,  the  patients 
get  over  the  syncopal  attacks  very  quickly,  unless,  of  course,  the 
internal  haemorrhage  is  profuse  and  the  case  has  really  passed  into 
Group  1. 

In  referring  to  the  hemorrhagic  discharge,  I  purposely  did  not 
mention  the  expulsion  of  a  uterine  decidua,  because  I  did  not  wish  to 
give  the  impression  that  this  was  a  symptom  that  should  be  waited 
for.  Undoubtedly,  when  present,  it  is  a  feature  of  very  great  value ; 
but  it  is  very  generally  a  late  sign,  frequently  not  appearing  until 
1  Journ.  Obst.  and  Gyn.  Brit.  Empire,  December,  1906. 


OPERATIVE  Mll»\VII'i:i;V 

there  have  been  several  attacks  of  pain   and   tin    tube  has  aborted 
or  raptured.     In  a  number  of  my  cases  the  cast  has  not   been  Bhed 

until  after  operation.  Very  often,  indeed,  it  is  never  seen.  In  my  o  I 
it  was  observed  in  27  per  cent.,  in  Haultain's1  in  80  per  cent.,  and  in 
Bell's  in  1!)  per  cent.  I  may  mention  that  in  a  number  of  my  cases  the 
uterus  had  been  curetted  before  I  saw  the  patient,  and  in  the  ovarian 
pregnancy  there  was  a  coexisting  uterine  gestation.  Taking  aeries 
of  cases  reported  by  different  operators,  a  decidual  cust  is  noted  in 
not  more  than  30  per  cent,  of  cases.  Without  doubt  the  decide 
often  lost  in  the  discharge,  especially  at  such  times  as  the  bowels  and 
bladder  are  evacuated.  Besides,  as  I  have  already  pointed  out,  early 
in  pregnancy  there  is  practically  no  decidua  present. 

The  presence  or  absence  of  the  ordinary  subjective  and  objective 
si^ns  of  pregnancy,  such  as  morning  sickness,  pain  in  the  breasts,  and 
other  mammary  changes,  cannot  be  relied  upon  in  ectopic  pregnancy 
in  the  early  months.  Naturally,  if  they  are  present,  they  confirm  the 
diagnosis  of  pregnancy  ;  but  they  are  very  often  absent,  and,  indeed, 
appear  to  be  less  constant  in  extra-uterine  than  in  intra-uterine 
gestation. 

Irritation  of  the  bladder,  amounting  frequently  to  dysuria,  is  a 
common  symptom,  especially  if  there  is  a  large  sac  or  collection  of 
blood  in  Douglas'  pouch  pushing  the  uterus  forward  against  the  bladder. 
This  is  referred  to  in  connexion  with  pelvic  hematocele  (p.  572). 
Constipation  is  very  frequent,  but  that  is  so  general  with  women, 
especially  during  pregnancy,  that  it  is  of  no  value  from  a  diagnostic 
point  of  view  ;  indeed,  from  recorded  cases,  and  from  those  which  I 
have  seen  in  my  practice,  it  has  often  confused  the  medical  attendant, 
and  led  him  to  think  that  the  abdominal  pain  or  uneasiness  com- 
plained of  by  the  patient  had  its  origin  in  the  bowel,  and  was  caused 
by  constipation. 

Having  impressed  upon  my  readers  the  extreme  importance  of 
carefully  considering  the  history  in  this  disease,  I  must  now  refer  to 
the  bimanual  examination. 

In  carrying  out  a  bimanual  examination  in  a  doubtful  case  of 
ectopic  pregnancy,  the  greatest  care  must  be  exercised,  for  a  gravid 
very  readily  gives  way  if  carelessly  handled.  This  has  frequently 
happened,  and,  as  a  matter  of  fact,  occurred  in  one  of  my  cases, 
with  a  most  disastrous  result.  My  house-surgeon  was  examining 
the  patient  when  the  sac  ruptured,  and  the  contents  being  septic,  and 
escaping  into  the  general  peritoneal  cavity,  a  general  septic  peritonitis 
resulted.  Especial  care  must  be  taken  when  the  examination  is  made 
under  an  anesthetic,  for  then,  the  patient  being  unconscious,  there  is 
1  Journ.  Ubst.  and  Qyn.  Brit.  E»ij)irc.  June,  1906,  p.  409. 


ECTOPIC  PKEGNANCY  559 

nothing  to  warn  the  examiner  of  the  danger  he  runs  from  pressing  too 
firmly. 

The  sac  which  is  felt  in  cases  of  ectopic  pregnancy  varies  greatly 
as  regards  size,  consistency,  and  position.  Its  size  depends  in  great 
part  upon  the  age  of  the  pregnancy,  but  also  not  a  little  upon  the 
amount  of  haemorrhage  which  has  occurred.  Besides,  sooner  or  later 
the  sac  contracts  adhesions  to  the  surrounding  intestines,  ovary, 
broad  ligament,  etc.,  and  there  is  thus  formed  a  mass  of  variable 
dimensions  and  of  very  indefinite  outline.  The  consistency,  too,  is 
not  constant.  Theoretically  it  is  soft  and  elastic,  but,  as  a  matter 
of  fact,  especially  after  any  effusion  of  blood  into  the  wall,  it  may 
feel  just  as  firm  and  hard  as  any  solid  tumour.  Pulsation  over 
its  surface  is  frequently  referred  to  as  being  a  feature  of  some 
diagnostic  importance.  Personally,  I  do  not  attach  great  importance 
to  this  feature,  for  in  inflammatory  conditions  of  the  appendages 
it  is  also  well  marked.  The  sac  is  very  generally  tender  to  the 
touch. 

The  sac  in  the  early  weeks  is  commonly  situated  on  one  side,  and 
rather  behind  the  uterus,  and  as  it  increases  it  very  generally  extends 
farther  and  farther  backwards.  As  it  does  so  it  pushes  the  uterus 
forwards  and  upwards.  It  is  very  much  less  common  to  find  the  sac 
in  front  of  the  uterus,  although  after  intraperitoneal  hemorrhage 
some  blood  may  collect  in  the  utero-vesical  pouch. 

When  the  rupture  occurs  into  the  broad  ligament,  the  tumour  may 
be  distinctly  lateral,  and  the  uterus  markedly  pushed  over  towards  the 
opposite  side. 

The  cases  in  which  the  sac  is  most  difficult  to  define  are  where  the 
uterus  is  backwardly  displaced  and  is  lying  over  the  sac,  and  where 
the  sac  is  situated  far  out  in  the  ampulla,  is  very  soft,  and  is  closely 
surrounded  by  the  intestines.  The  history,  the  localized  rigidity,  and 
pain  may  then  sometimes  he  the  only  symptoms,  and  on  them  alone  it  may 
be  necessary  to  act. 

It  occasionally  happens,  in  spite  of  a  history  so  typical  as  the  one 
we  have  seen  is  generally  associated  with  ectopic  pregnancy,  that  the 
diagnosis  is  not  so  simple,  and  that  other  conditions  may  simulate  or 
be  simulated  by  it.  Amongst  the  most  important  of  these  conditions 
may  be  mentioned  salpingitis,  appendicitis,  and  tumours  of  the  ovary 
and  uterus,  especially  when  these  are  associated  with  intra- uterine 
abortion. 

Let  me  give  a  few  examples  from  my  case-book : 

Case  1.  Simple  Ovarian  Cystoma  behind  the  Uterus  associated  with  "»  Intro- 
Uterine  Abortion  of  Tiv<>  Months — Diagnosis:  Ectopic  Pregnancy — Abdominal 
Section — Recovery. — A  young  married  lady,  with  three  of  a  family,  about  the 


560  OPERATE  i:  MIDWIFER1 

time  of  a  second  missed  period,  was  seized  one  afternoon  with  abdominal 
pain,  especially  marked  in  the  right  iliac  fossa.  There  also  existed  a  red 
vaginal  discharge.  The  pain  complained  of  was  distinctly  paroxysmal. 
Dr.  I'--  .  her  family  doctor,  asked  me  to  see  her  in  consultation.  Upon 
bimanual  examination  I  found  the  uterus  enlarged,  and  a  swelling  about  tin- 
size  of  a  walnut,  which  was  fixed  and  tender,  close  to  the  Bide  of  the  uterus. 
I  diagnosed  extra  uterine  pregnancy,  and  advised  her  immediate  removal 
to  a  nursing-home.  Upon  opening  the  abdomen  I  discovered  that  the 
tumour  was  a  small  cystic  ovary.  A  day  or  two  later  I  removed  the  remains 
of  a  uterine  abortion. 

I  have  upon  one  or  two  occasions  opened  the  abdomen  in  cases  of 
salpingitis,  suspecting  that  I  had  to  deal  with  an  ectopic  pregnancy. 
The  differential  diagnosis  between  the  two  conditions  must  be  based 
generally  on  the  history ;  but  occasionally  the  histories  are  so  much 
alike  as  regards  pain  and  irregular  bleedings  that  one  is  left  in  uncer- 
tainty regarding  which  one  has  to  deal  with.  In  connexion  with  the 
bimanual  examination,  in  most  cases  of  salpingitis  both  tubes  are 
affected,  but  very  often  one  is  more  decidedty  affected  than  the  other, 
and  masks  the  other. 

Upon  one  occasion  I  made  the  diagnosis  of  extra- uterine  preg- 
nancy when  I  had  really  to  deal  with  a  case  of  appendicitis  with  an 
intra-uterine  abortion.  As  a  decidual  cast  came  away  in  this  case, 
it  will  be  readily  understood  that  there  was  sufficient  excuse  for  the 
mistake. 

Appendicitis  with  Intro-Uterine  Abortion. — Mrs.  8 ,  a  young  married 

lady,  a  fortnight  after  a  period  missed  was  seized  with  severe  abdominal 

pain.      Dr.   E ,   who  was  summoned,   found   the  pain  very   severe  ;   it 

extended  over  the  whole  lower  quadrant  of  the  abdomen,  but  was  especially 
marked  on  the  right  side,  where  there  was  distinct  rigidity.  There 
was  also  a  red  vaginal  discharge.  Upon  bimanual  examination  a  small 
swelling  could  be  felt  to  the  right  of  the  uterus.  Very  naturally  he 
made  a  diagnosis  of  extra-uterine  pregnancy,  and  the  following  day,  when  I 
saw  her  in  consultation,  I  had  no  hesitation  in  agreeing  with  him,  especially 
as  there  had  been  expelled  in  the  meantime  a  portion  of  decidua.  The 
patient  was  immediately  removed  to  a  nursing-home.  When  I  opened  the 
abdomen,  I  found  an  elongated  and  inflamed  appendix  adherent  to  the  tube 
and  ovary,  both  of  which  showed  signs  of  recent  inflammation.  As,  how- 
ever, I  believed  the  inflammation  was  from  the  appendix,  I  only  removed 
it  and  a  portion  of  ovary.  The  patient  made  an  excellent  recovery,  and  ten 
days  after  the  abdominal  operation  I  curetted  the  uterus. 

Another  mistake  which  sometimes  arises  is  the  confusing  of  an 
extra-uterine  pregnancy  with  a  backward  displacement  of  the  gravid 
uterus.     A  most  interesting  example  of  this  mistake  has  been  already 


ECTOPIC  PREGNANCY  561 

recorded  in  the  chapter  on  Backward  Displacement  of  the  Gravid 
Uterus,  where  the  differential  diagnosis  of  these  two  conditions  is  fully 
considered. 

But  the  most  common  mistake  is  to  diagnose  uterine  abortion 
when  what  really  exists  is  an  extra-uterine  pregnancy.  Here  is  a  case 
of  this  nature,  where  the  doctor,  imagining  he  had  to  deal  with  an 
incomplete  abortion,  curetted  the  uterus,  and  while  doing  so  ruptured 
an  ectopic  sac  : 

Extra-Uterine  Pregnancy  mistaken  for  Intra- Uterine  Abortion — Curettage — 

Rvptwe  of  the  Sac — Death. — Mrs.  M ,  aged  thirty,  3-para,  was  brought 

into  the  Maternity  Hospital  under  my  care,  in  November,  1907,  in  a 
condition  of  collapse.  Her  doctor  who  accompanied  her  gave  the  following- 
history  :  Three  weeks  before  he  was  called  to  see  her  on  account  of 
abdominal  pain  and  vaginal  haemorrhage.  As  she  had  missed  a  period 
the  doctor  thought  an  abortion  was  threatened,  and  prescribed  the  usual 
remedies  for  arresting  this  condition.  When  he  saw  her  again  three 
weeks  later  she  was  still  having  haemorrhage.  He  therefore  decided  to 
curette  the  uterus,  which  he  did  under  chloroform.  After  the  operation 
he  noticed  the  patient  was  collapsed,  and  this  collapse  increased  in  spite 
of  strychnine,  saline  transfusion,  and  stimulants.  When  he  brought  her 
into  the  hospital,  he  informed  me  that  he  thought  he  had  ruptured  the 
uterus  with  his  curette.  On  bimanual  examination  I  could  detect  nothing 
definite,  as  the  abdomen  was  so  rigid  and  the  uterus  seemed  displaced  back- 
wards. I  suspected,  however,  that  there  must  have  been  something  more 
serious  than  a  simple  laceration  with  the  curette,  and  I  hazarded  the  diagnosis 
of  a  ruptured  extra-uterine  pregnancy.  As  she  was  steadily  sinking,  and  the 
only  possible  hope  of  saving  her  seemed  abdominal  section,  I  opened  the 
abdomen.  When  I  did  so,  I  found  it  full  of  blood.  On  passing  my  hand  clown 
to  the  pelvis,  I  pulled  up  a  large  ruptured  tubal  sac ;  this  I  quickly  removed 
along  with  the  other  tube,  which  was  also  distended  with  blood.  I  then 
flushed  out  the  abdomen  with  saline,  and  rapidly  closed  it.  The  patient 
sank,  and  died  a  few  hours  after  the  operation. 

Veiy  frequently  this  mistake  is  made ;  indeed,  in  a  large  proportion 
of  the  cases  that  have  been  under  my  care  I  have  been  asked  to  see 
the  patients,  because  the  doctor  imagined  he  was  dealing  with  an 
incomplete  abortion.  Consequently,  my  practice  and  teaching  are 
in  all  cases  of  abortion  to  exclude  the  possibility  of  extra-uterine 
pregnancy,  and  I  advise  my  students  always  to  approach  the  case  in 
the  following  way,  and  to  answer  the  following  questions  :  (1)  Is 
the  woman  pregnant  ?  (2)  Is  the  pregnancy  uterine  or  extra-uterine  ? 
(3)  If  uterine,  is  the  abortion  threatened,  complete,  or  incomplete? 
I  make  no  exception,  and  always  decide  these  three  questions.  I  feel 
convinced  that  mistakes  can  only  be  avoided  by  doing  this.  Quite 
recently  I  was  discussing  this  subject  with  my  students  when  a  patient 

36 


562  OPERATIVE   MIDWIl'KllY 

came  to  consul)  me  at  the  Western  Infirmary,  and  gave  the  following 

history  : 

Mrs.  X stated  Bhe  was  twenty-five  years  oi  age,  and  had  bad  five 

children.  She  also  said  thai  she  had  not  altered  for  six  weeks ;  that  theday 
before  she  had  some  pain  in  the  lower  part  of  the  abdomen,  nausea,  and 
vomiting.  She  had  a  slight  hemorrhagic  vaginal  discharge.  I  asked  the 
nurse  in  prepare  her  for  examination,  ami  pointed  out  to  the  student* 
that  it  was  not  likely  that  we  had  to  deal  with  a  case  of  extra-uterine 
pregnancy  ;  most  probably  it  was  a  simple  threatened  abortion,  as  the  latter 

was  a  far  more  coi in  occurrence,  bul  that  we  must  exclude  in  this  and  in 

.ill  eases  the  possibility  of  extra-uterine  pregnancy.  When  I  examined  her, 
1  was  greatly  pleased  to  find  an  elastic  swelling  behind  and  to  the  left  of  the 
uterus,  for  it  was  such  a  valuable  lesson  t<>  the  Btudents.  Two  days  later  I 
removed  the  gravid  tube  ;  it  was  an  example  of  an  incomplete  tubal  abortion. 

The  other  mistake  of  considering  the  condition  extra-uterine  when 
it  is  really  an  intra-uterine  pregnancy  has  also  been  occasionally 
made,  and  to  illustrate  this  let  me  briefly  detail  the  following  case : 

Angular  Pre  gnu  n  rii  resulting  in  Abortion  mistaken  for  Extra-Uterim  Preg- 
nancy.— Four  years  ago  I  was  asked  by  a  medical  friend  to  see  his  wife,  as  he 
feared  she  was  threatened  with  an  abortion.  I  hail  attended  the  lady  at  her 
two  previous  confinements — one  seven  and  the  other  four  years  previously. 
When  I  visited  her,  she  gave  me  the  history  of  a  period  missed.  In  addition, 
she  told  me  that  ten  days  after  the  period  was  expected  abdominal  pain  and 
hemorrhagic  vaginal  discharge  appeared.  The  discharge  was  not  great,  hut 
the  pain  was  sometimes  pretty  severe,  and  was  more  marked  towards  the 
left  iliac  fossa.  Upon  making  a  vaginal  examination  I  discovered  the  uterus 
Avas  enlarged,  and  at  the  left  corner  in  the  neighbourhood  of  the  tube  I  could 
detect  a  small  localized  bulging.  I  told  her  husband  of  my  fear  that  there 
might  be  an  extra-uterine  pregnancy,  and  that  I  was  chiefly  alarmed  because 
it  was  so  close  beside  the  uterus.  My  fear  appeared  to  be  fully  justified 
when,  two  days  later,  the  cast  shown  in  the  illustration  (Fig.  -64)  was  expelled. 
As  may  beobserved,  the  cast  is  complete  except  at  the  right  corner.  I  thought 
I  would  have  to  open  the  abdomen  at  this  stage,  but  my  friend  requested  me 
to  delay  doing  so.  We  were,  however,  prepared  for  any  possible  sudden  call 
to  operate;  the  patient  was  watched  very  carefully,  and  all  discharges  kept. 
Four  days  later  a  small  piece  of  membrane,  which  just  completed  the  sac 
that  was  expelled,  came  away  in  the  vaginal  discharge.  Attached  to  this 
little  piece  of  decidua  was  the  ovum. 

In  the  case  just  described  I  had  to  deal  with  the  very  interesting 
condition  of  what  is  known  as  'angular  pregnancy,'  which  has  been 
especially  referred  to  by  Budin,  Bar,  Kelly,  and  others.  It  is  the 
implantation  of  the  ovum  in  the  corner  of  the  uterus  over  the  tubal 
ostium.  Naturally,  it  very  closely  resembles  interstitial  and  isthmal 
ectopic  pregnancy. 


ECTOPIC  PEEGNANCY  563 

Other  errors  of  diagnosis  which'  occasionally  are  made  are  mistaking 
interstitial  fibroids,  ovarian  tumours,  and  lateral  flexions  of  the  gravid 
uterus  for  an  ectopic  sac.  The  latter  condition — flexion  of  the  gravid 
uterus — may  simulate  very  closely  an  extra-uterine  pregnancy.  In 
all  cases  of  doubt  an  examination  under  anaesthesia  is  necessary. 

Mistakes  in  diagnosis,  such  as  taking  an  ovarian  tumour  or  myoma 
for  a  gravid  sac,  or,  vice  versa,  taking  a  gravid  sac  for  one  of  these 
tumours,  is  seldom  likely  if  one  carefully  considers  the  history.     I 


Fig.  264. — Cast  of  Uterine  Decidua  in  a  Case  of  '  Angular  Pregnancy.' 

At  the  right  corner  there  is  a  small  piece  wanting  ;  that  piece  came  away  a  few  days  after 
the  cast  was  expelled.     The  ovum  was  attached  to  it.     (Author's  collection.) 

have  referred  already  to  how  closely  these  tumours  may  simulate  an 
ectopic  sac  if  there  is  a  coexisting  intra-uterine  abortion. 

In  cases  of  great  doubt,  where  the  diagnosis  is  especially  difficult, 
it  used  to  be  the  custom  to  recommend  the  exploration  of  the  uterus 
with  the  sound,  and  even  with  the  curette.  As  regards  the  uterine 
sound,  I  am  quite  prepared  to  admit  that  sometimes  it  is  of  real 
practical  value.  I  have  once  or  twice  had  to  employ  it.  If  the 
accoucheur  makes  use  of  the  instrument,  he  must  do  so  with  great 
caution,  as  several  cases  are  on  record  where  the  uterus  was  injured. 
Not  only  must  he  introduce  and  move  it  about  with  great  care,  but  he 


564  OPERATIVE  MIDWIFERY 

must  make  absolutely  sure  that  the  vaginal  canal  is  thoroughly  dis- 
infected, for  where  there  has  been  a  vaginal  discharge  going  on  for 
-Mine  time  there  are  sure  to  be  present  many  organisms  of  greater  or 
less  virulence.  Still  more  careful  must  he  be  with  the  curette,  as  he 
may  very  readily  set  up  violent  contractions  in  the  sac,  and  injure  and 
infect  the  uterine  tissues.  I  am  doubtful  if  the  curette  is  often  of  much 
value.  From  the  scrapings  removed  and  examined  microscopically 
one  could  generally  give  an  opinion  as  to  whether  or  not  pregnancy 
existed,  but  one  could  not  say  whether  the  pregnancy  was  uterine  or 
extra-uterine.  Only  if  chorionic  villi  were  found  present  could  one 
say  it  was  uterine,  for,  as  we  have  seen,  the  deciduse  in  uterine  and 
extra-uterine  pregnancy  are  indistinguishable  either  macroscopically 
or  microscopically. 

(3)  Cases  in  which  the  woman  advances  in  her  pregnancy  to 
the  later  months.  Cases  of  this  group  are  not  very  common,  although 
there  are  now  a  large  number  recorded.  In  this,  as  in  the  previous 
groups,  the  history  is  generally  of  the  greatest  importance.  For 
example,  one  very  generally  finds  on  questioning  the  patient  that  she 
has  passed  through  Group  2;  she  has  at  one  time  of  her  pregnancy 
had  attacks  of  pain,  faintness,  etc.  In  some  cases,  however — they  are 
very  much  the  exception — there  is  nothing  unusual,  and  the  pregnancy 
advances  without  disturbing  the  patient  to  any  extent. 

The  ultimate  termination  of  cases  of  this  group  is  very  varied. 
At  any  time  during  pregnancy  the  peculiarity  of  the  sensations  felt 
by  the  mother  or  the  discomforts  she  experiences  may  induce  her  to 
seek  medical  advice.  The  discomforts  are  chierly  those  produced  by 
the  large  sac  displacing  the  structures  from  their  normal  position. 
Obstinate  constipation  is  frequent,  disturbances  of  the  bladder  not 
uncommon.  Uneasiness  and  even  pain  in  the  abdomen  may  be 
complained  of,  but  the  symptoms  are  often  so  vague  that  the  medical 
attendant,  when  he  comes  to  examine  the  patient,  attributes  them  to 
the  ordinary  disturbances  that  are  frequently  associated  with  pregnancy 
in  the  later  months,  when  the  growing  uterus  displaces  and  disturbs 
the  surrounding  organs.  Even  the  situation  of  the  gravid  sac  becomes 
very  much  like  the  normal.  Abdominal  distension  is  usually  more 
marked  on  one  side  than  the  other,  but  one  sees  this  in  normal 
pregnancy,  in  which,  as  a  rule,  the  uterus  is  displaced  to  the  right 
side.  The  gravid  uterus,  however,  can  be  pulled  over  to  the  middle 
line,  while  a  large  gravid  sac  is  generally  fixed. 

Should  the  physician  make  a  vaginal  examination,  there  is  then 
every  likelihood  that  he  will  have  his  attention  arrested  by  the 
condition  of  matters.  The  cervix  will  not  be  so  soft,  and  it  will  often 
be  displaced.     He  may  be  fortunate  enough  in  feeling  the  uterus  a  - 


ECTOPIC  PREGNANCY  565 

whole  displaced,  but  very  frequently  the  extra-uterine  sac  is  so  closely 
applied  and  fixed  to  the  uterus  that  he  cannot  distinguish  the  one 
from  the  other.  A  rectal  examination  may  be  of  service,  but  the 
accoucheur  must  have  had  his  suspicions  very  strongly  aroused  before 
he  would  resort  to  this  method  of  examination. 

In  the  case  of  advanced  extra-uterine  pregnancy  figured  (p.  569),  I 
at  first  mistook  the  body  of  the  uterus,  which  was  displaced  behind 
and  to  the  right,  for  a  fibroid,  although  later,  when  the  patient  came 
into  hospital,  I  appreciated  the  mistake.  I  found  that  the  tumour 
that  I  thought  was  a  fibroid  was  the  body  of  the  uterus,  and  the  sac 
which  I  thought  was  the  enlarged  body  was  an  ectopic  pregnancy. 
In  cases  of  doubt  the  passage  of  the  uterine  sound  is  of  service,  but 
not  infrequently  when  this  has  been  employed  injury  to  the  sac  has 
resulted.  This  was  so  in  my  case :  the  sound  had  been  forced  along 
a  false  passage  several  times,  and  the  sac  wall  and  its  contents  had 
been  infected.  Of  course,  if  every  possible  care  is  taken  in  passing 
the  sound,  and  if  the  hands  of  the  operator  and  the  vulva  of  the 
patient  are  thoroughly  cleansed,  there  is  little  risk  of  doing  any  harm. 

At  any  time  during  pregnancy  the  patient's  attention  may  be 
arrested  by  the  cessation  of  the  foetal  movements,  and  she  may  seek 
medical  advice  because  of  this.  Naturally,  the  farther  the  pregnancy 
has  advanced  and  the  more  energetic  the  movements,  the  more  likely 
is  she  to  have  her  suspicions  aroused  and  to  consult  her  medical 
attendant. 

In  cases  of  extra -uterine  pregnancy  which  advance  to  term, 
phenomena  occur  which  are  referred  to  as  '  spurious  labour.'  There 
is  severe  abdominal  pain  and  often  expulsion  of  the  uterine  decidua, 
with  a  hamaorrhagic  vaginal  discharge.  The  foetus,  if  it  is  alive,  gives 
evidence  of  very  great  disturbance  in  its  circulation,  its  movements 
become  extremely  active,  then  quieten  down  and  cease  altogether. 
After  death  of  the  foetus  a  number  of  changes  may  take  place  in  the 
sac  and  its  contents.  The  liquor  amnii  is  absorbed  and  shrinking 
of  the  sac  occurs,  so  that  the  abdominal  tumour  gradually  diminishes 
in  size. 

The  foetus  itself  may  become  altered  in  different  ways — most 
commonly  it  becomes  mummified.  In  this  process  the  foetus,  mem- 
branes, and  placenta  become  shrivelled  up  by  the  absorption  of  the 
fluid  in  their  tissues.  Occasionally  an  adipocereous  transformation 
occurs,  the  tissues  of  the  foetus  becoming  altered  into  a  soapy-like 
yellow  substance.  Calcification  is  yet  another  variety  of  change.  In 
most  cases  it  does  not  amount  to  more  than  a  deposit  of  lime  in  the 
membranes  and  placenta,  and  a  scattered  deposit  in  the  foetus. 
Occasionally,  however,  the  foetus  is  chiefly  affected,  and  one  gets  the 


566  OPERATIVE  MIDWIFERY 

true  lithopedion.  In  .such  cases  the  superficial  tissues  of  the  I 
are  affected,  although  the  deeper  ones  maj  also  be  impregnated  with 
the  lime  salts.  These  shrunken  Baca  are  often  retained  for  man;. 
years  in  the  uhdominal  cavity,  and  are  stowed  away  in  a  marvellous 
manner.  1  recently  noticed  a  case  described  where  the  woman  hud 
had  several  pregnancies  after  a  supposed  ectopic  one  many  y< 
before.  At  her  death  the  abdomen  was  opened,  and  an  old  shrunken 
ectopic  sac  was  discovered.  (t»uite  a  number  of  similar  cases  have 
been  described.  An  interesting  review  of  such  cases  is  given  by 
Bovee.1  Should  by  any  chance  the  sac  become  infected,  a  suppura- 
tion and  breaking  down  of  its  contents  may  occur.  In  most  of  these 
cases  the  pus  and  disintegrated  contents  of  the  sac  find  an  outlet 
through  bowel,  vagina,  abdominal  wall,  or  even  bladder.  This  process 
is  often  very  slow  if  the  foetus  is  of  some  age,  as  the  bones  have 
diliiculty  in  passing  through  the  sinuses  formed.  Fortunately,  in 
these  cases  a  rupture  seldom  occurs  into  the  general  peritoneal  cavity. 
As  a  result  of  inflammation  the  surrounding  intestines  become 
adherent,  and  completely  shut  off  the  general  peritoneal  cavity. 

Treatment. 

I  purpose  discussing  the  treatment  of  each  of  the  groups  of  cases 
that  I  have  already  described  in  connexion  with  '  clinical  features  ' 
of  ectopic  pregnancy.  After  doing  so,  I  will  consider  those  cases  of 
marked  hematocele,  as  one's  attitude  towards  that  condition  is  some- 
what different  than  towards  any  other  variety  of  ectopic  pregnancy 
one  encounters  in  practice. 

1.  The  Woman  is  struck  down  suddenly  with  Abdominal  Pain  and 
Profound  Collapse. — In  such  cases  the  all-important  question  for 
consideration  is,  When  should  one  operate  ?  Should  one,  no  matter 
how  collapsed  the  patient  is,  open  the  abdomen,  remove  the  sac,  and 
arrest  bleeding,  or  should  one  give  the  patient  time  to  recover  from 
her  profound  condition  of  shock  ?  There  are  advocates  of  both 
courses.  Personally,  I  believe  the  safer  procedure  is  immediate 
operation  in  all  cases.  After  all,  if  the  patient  is  extremely  collapsed, 
the  immediate  operation  adds  very  little  to  the  shock  already  present, 
for  the  operation  can  be  performed  quickly  and  with  light  anaesthesia. 
It  is  most  important  to  appreciate  that  fact.  "When  immediate  opera- 
tion is  undertaken  for  sudden  collapse,  the  abdominal  route  is  the 
only  one  to  be  considered. 

The  operation  is  performed  as  follows  :  The  abdominal  wall  is 

1  George  Washington   University  Bulletin,  vol.   v..  No.  3  ;    ref.  Jmtrn.   Obst. 
and  Gyn.  Brit.  Empire,  June,  1907,  p.  504. 


ECTOPIC  PREGNANCY  567 

thoroughly  cleansed.  The  patient  is  then  placed  in  the  Trendelenburg 
position.  An  incision  is  made  in  the  middle  line,  the  hand  passed 
down  into  the  pelvis,  and  the  affected  tube  and  corresponding  ovary 
brought  up  to  view.  If  desired,  a  pair  of  pressure  forceps  is  applied 
to  the  infundibulo-pelvic  ligament  beyond  the  ruptured  tube,  and 
another  pair  is  applied  to  the  uterine  end  of  the  tube.  The  tubal  sac 
is  removed,  the  ovary  being,  if  possible,  left  behind,  provided  it  is 
quite  healthy.  Ligatures  are  then  applied  to  the  two  cut  ends  of  the 
broad  ligament,  and  the  raw  edge  covered  with  peritoneum.  The 
pelvic  and  abdominal  cavities  are  then  irrigated  with  normal  saline 
solution,  or  simply  swabbed  out  with  dry  gauze.  Before  closing  the 
abdomen  the  other  tube  and  ovary  should  be  examined.  I  have  seven 
times  in  my  fifty-four  cases  found  the  other  tube  the  seat  of  a  hamiato- 
salpinx,  in  one  case  the  result  of  a  previous  extra-uterine  pregnancy. 
I  would  remove  the  other  tube  and  ovary  only  if  they  were  grossly 
diseased  and  could  not  possibly  be  conserved. 

During  the  operation,  but  not  before  it,  an  assistant  introduces  one 
or  two  pints  of  normal  saline  solution  underneath  the  breast  or  into  a 
vein.  The  patient  is  then  put  back  to  bed  and  the  foot  of  the  bed 
raised.  If  deemed  advisable,  she  is  given  some  brandy  by  the  rectum. 
I  would  strongly  caution,  however,  against  the  danger  of  over- 
stimulation. I  have  often  found  my  house  -  surgeons  make  this 
mistake. 

2.  The  Woman  suffers  for  Some  Time  from  Abdominal  Uneasiness 
and  Hemorrhagic  Vaginal  Discharge. — In  this  group  immediate  opera- 
tion is  always  advisable,  for  one  can  never  tell  when  all  danger  is  past. 
Some  years  ago  I  saw  a  case,  along  with  a  well-known  gynaecologist, 
which  illustrated  very  well  the  danger  of  leaving  such  cases  unoperated 
upon.  The  gynaecologist  referred  to  had  quite  recognized  that  the 
condition  was  one  of  extra-uterine  pregnancy,  but  he  considered  that 
all  danger  was  passed,  as  the  sac  was  small  and  hard.  He  advised 
against  operation.  A  few  weeks  later  I  heard  that  the  patient  had 
been  seized  with  severe  abdominal  pain,  and  had  collapsed  and  died. 

The  operation  in  cases  of  this  group  is  a  very  simple  one.  Usually 
there  are  slight  adhesions  between  the  tube  and  surrounding  parts, 
but  these  are  readily  broken  down,  and  the  sac — be  it  an  aborting 
tube  or  be  it  a  ruptured  tube— is  removed  as  I  have  already  described 
in  Group  1.  Should  the  rupture  have  occurred  into  the  broad 
ligament  and  a  hematoma  exist,  the  general  recommendation  is  tu 
split  open  the  broad  ligament,  clear  out  all  blood-clot,  and  pack  the 
cavity  with  gauze.  The  broad  ligament  is  then  stitched  over,  and  the 
end  of  the  gauze  brought  out  through  the  vagina.  It  is  undesirable, 
if  it  can  be  avoided,  to  bring  out  the  gauze  through  the  abdominal 


OPKi;.\Ti\  i:  midwii  i:i;v 

wound,  tor  drainage  in  thai  direction  is  unsatisfactory,  as  it  weakens 

the  lower  pari  ol  the  wound.  In  these  cases  it  is  quite  sound  to 
proceed  as  Kelly  and  others  have  recom mended,  and  deal  with  the 
sac  entirely  from  the  vagina,  and  then  close  the  abdomen. 

\n  cases  where  tlic  ovum  is  situated  in  the  interstitial  portion 
of  the  tube,  it  may  sometimes  he  found  impossible  to  satisfactorily 
cdose  the  ragged  cavity  of  the  uterine  wall,  mid  bo  it  is  often  necessary 
to  remove  the  entire  uterus  Bupravaginally.  This  was  found  necessary 
in  my  case  already  deserihed  and  figured  (p.  544).  If  possible. 
however,  the  uterus  should  always  he  saved,  and  that  will  usually  be 
possible  if  the  pregnancy  is  still  early,  and  the  sac  has  projected  out 
from  the  uterus  rather  than  developed  in  the  uterine  wall. 

In  recent  years  several  operators  have  suggested  a  conservative- 
treatment  of  the  tubes  in  cases  of  tubal  pregnancy.  Some,  for 
example,  have  dilated  the  abdominal  end  of  the  tube  and  pressed  out 
the  ovum ;  others  have  split  open  the  tube  and  shelled  out  the  ovum 
from  its  wall.  In  the  latter  case  the  wound  in  the  tubal  wall  is 
carefully  sutured.  I  have  twice  tried  this  treatment,  but  as  the 
bleeding  from  the  tube  continued,  I  was  ultimately  compelled  to 
remove  the  tube. 

3.  Ectopic  Pregnancy  in  the  Later  Months. — Before  considering 
details  regarding  the  operative  treatment  of  such  cases,  one  must 
consider  the  question  as  to  whether  or  not  it  is  ever  advisable  to  delay 
operating  for  the  sake  of  the  child.  Personally,  I  would  decidedly 
answer  in  the  negative.  I  am  fully  aware  that  a  number  of  children 
have  been  saved,  but  I  think  the  dangers  of  delaying  are  greater  than 
the  chances  of  obtaining  a  healthy  child.  If  delay  is  decided  upon,  it 
is  only  permissible  if  the  patient  is  placed  under  such  conditions  that 
immediate  operation  can  be  performed  should  that  become  necessary. 

The  chief  difficulty  in  operating  upon  cases  of  advanced  extra- 
uterine pregnancy  is  the  treatment  of  the  placenta.  There  is  never 
any  difficulty  in  opening  into  the  sac  or  in  removing  the  foetus,  but 
there  may  be  considerable  difficulty  in  dealing  with  the  sac,  and 
especially  with  the  placenta.  The  ideal  treatment  is  to  remove  the 
sac  entire — fcetus,  placenta,  and  membranes — as  was  done  in  the  case 
figured  in  the  illustration  (Fig.  265),  where  I  had  simply  to  separate 
some  adhesions  and  tie  off  the  lower  part  of  the  sac.  This  is 
generally  possible  when  the  child  has  been  dead  for  some  time,  for  a 
'dead'  placenta  is  easily  stripped  off,  and  any  little  bleeding  that 
occurs  is  readily  controlled  with  gauze  packing.  But  the  placental 
site  of  a  '  living '  placenta  bleeds  very  freely  when  the  latter  is 
separated ;  and  besides  in  the  process  of  separation,  especially  if  the 
placenta  has  been  attached  to  the  mesentery,  serious  injury  may  be 


ECTOPIC  PREGNANCY 


569 


clone  to  the  blood-supply  of  a  portion  of  the  intestines.  \n  such 
cases,  with  a  view  to  obtaining  a  'dead'  placenta,  and  one  thai 
may  be  safely  detached,  it  has  been  recommended  that  the  operation 
should  be  delayed  until  some  time  after  the*  death  of  the  child.  In 
many  cases  this  is  perfectly  safe,  and  the  dead  placenta  can  be  easily 
and  safely  separated.  But  by  such  treatment  the  child  is  sacrificed, 
and  there  is  no  guarantee  that  in  the  interval  the  sac,  with  its  dead 


Fig.  '265. — Ectopic  Pregnancy  which  had  advanced  to  Term.     (Author's  collection.) 


contents,  may  not  become  infected.     It  is  a  treatment,  therefore,  quite 
out  of  harmony  with  modern  obstetric  surgery. 

In  recent  years  the  successes  attending  immediate  removal  of  the 
'  living '  placenta  have  been  increasing  in  number.  There  are  two  most 
interesting  papers  on  the  subject  by  Sittner,1  who  has  carefully 
collected  a  large  number  of  recorded  cases  from  the  obstetric  literature 
of  different  countries.  From  his  figures  it  is  evident  how  much 
better  the  results  are  from  immediate  removal  than  from  any  other 
method,  for  where  the  placenta  was  left  behind  the  mortality  was 
57  per  cent.,  and  where  it  was  removed  it  was  18  per  cent. 

1  Zcnt.f.  Gyn.t  1903,  No.  2,  p.  33,  and  Deut.  Med.  Woch,  1906,  Nr.  30,  p.  1200. 


.-,70  OPERATIVE   MIDWIFER1 

In  dealing  with  some  of  these  eases,  it  has  been  found  that 
occasionally  the  arterial  blood-supply  may  be  cut  off  by  ligaturing  the 
ovarian  and  uterine  vessels  before  proceeding  to  separation.  In 
others,  separation  of  the  Bac  by  degrees  and  careful  '  understitching ' 
of  the  wall  have  proved  successful.  Sometimes  the  hemorrhage  from 
the  raw  placental  site  lias  heen  so  great  as  to  necessitate  compressing 
the  aorta  until  the  bleeding  was  controlled.  The  worst  cases  to  deal 
with  are  those  where  the  placenta  is  attached  to  some  vei\  vascular 
and  freely  movable  viscus,  such  as  the  bowel.  Winn  the  attachment 
is  in  the  pelvis,  bleeding  can  usually  be  controlled  by  simply  packing. 
Occasionally  the  operator  has  deemed  it  advisable  to  remove  the 
uterus,  but  that  is  unfortunate  in  a  young  woman,  and  should  be 
rarely  necessary. 

When  it  is  deemed  inadvisable  to  separate  the  living  placenta,  the 
best  course  to  pursue  is  to  cut  the  umbilical  cord  short,  stitch  the  sac 
wall  to  the  abdominal  parietes,  and  pack  the  cavity  with  gauze.  If 
the  sac  is  well  down  in  the  pelvis,  the  end  of  the  gauze  may  be 
brought  out  through  the  vagina,  and  the  sac  wall  closed  above.  The 
gauze  should  be  removed  in  a  few  days  and  the  sac  repacked.  After 
ten  or  twelve  days  the  placenta  should  be  removed.  If  that  is  not 
done,  the  '  dead '  placenta  disintegrates,  and  a  discharge  continues, 
which  sooner  or  later  becomes  secondarily  infected  by  pyogenic 
organisms,  and  is  a  constant  source  of  danger  to  the  patient.  One 
has  only  to  read  the  records  of  such  cases  to  see  how  extremely 
unsatisfactory  this  termination  is. 

Closing  the  abdomen  and  neglecting  the  placenta,  leaving  the 
latter  to  take  care  of  itself  in  the  abdominal  cavity,  has  proved 
absolutely  unsatisfactory,  and  has  now  no  advocates. 

It  is  occasionally  possible  to  remove  the  child  and  deal  with 
the  placenta  entirely  from  the  vagina.  It  is  generally  stated  that 
the  cases  suitable  for  this  treatment  are  where  the  lower  pole  of 
the  f<etal  sac  is  situated  low  dowrn  in  the  pelvic  cavity,  and  can  be 
easily  reached  through  the  vaginal  vault.  I  would  add  another  con- 
dition— that  the  child  must  either  be  premature  or  the  presenting 
bead  must  be  impacted  in  the  pelvis,  as  the  difficulties  and  dangers 
of  dragging  a  full-time  child  through  an  opening  in  the  vaginal  vault 
would  be  extreme. 

A  most  grave  condition  to  deal  with  is  infection  of  the  gravid  sac. 
If  the  sac  cannot  be  removed,  but  has  to  be  incised  and  drained,  the 
ideal  route  is  through  the  vagina.  There  are,  however,  occasionally 
cases  in  which  it  cannot  be  satisfactorily  reached  from  the  vagina. 
In  such  an  incision  should  be  made  at  a  point  where  there  is  the 
least   chance   of    the   contents  escaping   and    infecting   the   general 


ECTOPIC  PEEGNANCY  571 

peritoneal  cavity,  and  where  there  is  the  best  drainage.  This  is 
usually  possible,  for  the  sac  has  already  contracted  adhesions  of  such 
a  nature  that  at  some  point  externally  a  fresh  incision  can  be  made  into 
it  without  opening  into  the  general  abdominal  cavity. 

Pelvic  Haematocele. 

In  considering  the  clinical  features  of  ectopic  pregnancy,  I  have 
only  incidentally  referred  to  the  collection  of  blood  in  Douglas'  pouch, 
known  as  a  pelvic  hematocele,  and  which  every  one  admits  is  so 
generally  the  result  of  a  gravid  tube  which  has  ruptured  or  aborted. 
I  have  done  so  purposely,  because  I  do  not  wish  a  hematocele  to  be 
looked  upon  as  a  symptom  of  tubal  pregnane}".  My  endeavour  has 
been  to  try  and  help  my  readers  to  be  able  to  appreciate  the  condition 
of  ectopic  pregnancy  before  the  hematocele  is  pronounced.  It  must 
be  remembered  that  only  occasionally  does  the  medical  attendant  see 
the  patient  for  the  first  time  when  there  is  a  well-defined  hematocele, 
even  although  the  hemorrhage  is  sudden  and  profuse,  as  in  Group  1, 
or  more  gradual,  as  in  Group  2,  for  in  the  former  it  takes  some  time 
for  the  blood  to  collect,  and  in  the  latter,  as  we  have  seen,  there  are 
the  premonitory  symptoms  already  indicated. 

When  recovery  occurs  from  the  free  peritoneal  hemorrhage,  a 
pelvic  hematocele  forms.  The  blood  collects  in  Douglas'  pouch, 
and,  if  of  large  amount,  not  only  fills  up  the  pouch,  but  extends  up 
above  the  pelvic  brim.  When  this  swelling  is  palpable  above  the 
pelvic  brim,  it  is  usually  more  marked  on  one  side.  Fluctuation 
cannot  be  made  out,  but  areas  of  dullness,  which  alter  very  slowly 
when  the  patient  is  changed  from  one  position  to  another,  may  be 
noted  shortly  after  rupture  if  there  is  a  large  quantity  of  free  blood  in 
the  abdomen.  It  need  hardly  be  stated  that  it  is  generally  undesirable 
to  move  the  patient  about  to  permit  of  this  sign  being  elicited. 

On  examining  by  the  vagina  shortly  after  rupture  probably  nothing 
is  felt ;  later  an  elastic  effusion  can  be  made  out,  and  still  later,  when 
the  blood  coagulates,  a  semi-solid  tumour.  The  effusion  is  felt  to 
run  out  against  the  pelvic  wall,  and,  consequently,  most  frequently 
simulates,  as  far  as  the  physical  examination  goes,  a  pelvic  cellulitis 
and  peritonitis.  The  histories,  however,  of  these  two  conditions  are 
so  absolutely  different  that  seldom  any  confusion  arises  between  them, 
unless,  as  occasionally  happens,  the  hematocele  becomes  infected. 
Later  the  hematocele  is  firmer :  it  gives  a  peculiar  sensation  to  the 
examining  fingers,  for  in  some  parts  it  feels  hard  and  in  others  soft. 

The  effusion  displaces  the  uterus  always  a  little  to  the  side,  and 
most  commonly  forwards  and  upwards  against  the  bladder.     Occa- 


572  OPERATIVE  MIDWIFERY 

sionally  the  effusion  occurs  also  into  the  utero-vesical  pouch  when  the 
uterus  is  found  embedded  in  the  effusion. 

With  a  pelvic  hematocele  a  general  feeling  of  abdominal  and 
pelvic  discomfort  is  complained  of.  After  the  collapse  is  recovered 
from,  the  pulse  improves,  but  the  temperature,  which  was  subnormal, 
rises  first  to  the  normal,  and  often  to  slightly  above  the  normal.  This 
Blight  febrile  disturbance  is  the  result  of  absorption  of  disintegrating 
blood.  As  the  effusion  very  generally  presses  the  uterus  forward 
against  the  bladder,  slight  difficulty  in  micturition  is  often  complained 
of,  and  this  occasionally  throws  the  physician  off  his  guard,  and  leads 
him  to  suspect  that  he  has  to  deal  with  an  incarcerated  retrotlexed 
gravid  uterus.  The  differential  diagnosis  of  this  condition  is  referred 
to  on  p.  270.  Owing  to  the  pressure  on  the  rectum  behind,  the  patient 
complains  not  infrequently  also  of  rectal  tenesmus  :  she  has  a  constant 
desire  to  go  to  stool.     Here  is  the  brief  history  of  a  case  in  point : 

Cast  of  Ruptured  Tubal  Pregnancy — Hcematocele — Chief  Symptom,  Rectal 
Tenesmus. — Late  one  evening  I  was  called  to  see  the  wife  of  a  practitioner 
in  a  neighbouring  town.  When  I  arrived,  I  found  the  patient  very  anaemic, 
with  a  pulse  of  90,  and  complaining  of  great  abdominal  pain.  There  was 
no  discomfort  on  micturition.  Nothing  could  be  felt  from  the  alnlomen 
except  great  rigidity  of  the  whole  abdominal  wall.  Bimanuallv  I  could  make 
out  the  uterus  pushed  forward  and  an  effusion  in  Douglas'  pouch  extending 
to  the  pelvic  walls,  and  more  marked  on  the  left  side.  1  he  history  of  the 
case  was  as  follows  :  The  patient  was  about  seven  weeks  past  her  period. 
Four  weeks  before  abdominal  pain  was  complained  of;  recurrent  attacks  of 
this  pain  followed.  A  few  days  after  the  first  attack  of  pain  there  was  a 
vaginal  discharge.  A  fortnight  before  she  was  seized  with  very  severe  pain 
and  fainted.  From  that  time  great  rectal  tenesmus  and  a  constant  desire  to 
go  to  stool  was  complained  of.  The  week  before  I  saw  her  she  had  been 
curetted,  the  idea  being  that  the  case  was  one  of  incomplete  abortion,  and 
that  the  effusion  behind  the  uterus  was  of  an  inflammatory  nature.  Colour 
was  lent  to  this  idea  by  a  slight  rise  of  temperature  in  the  evening,  never, 
however,  amounting  to  more  than  KXR  I  was  quite  satisfied  that  the 
condition  was  ruptured  extra-uterine  pregnancy,  and  that  the  swelling  in 
Douglas'  pouch  was  a  hematocele.  I  therefore  opened  the  abdomen.  I 
found  the  right  tube  ruptured  in  the  ampulla,  and  a  large  quantity  of  blood- 
clot  filling  Douglas' pouch  and  extending  up  to  the  left  side.  I  removed 
the  tube  and  the  blood-clot  and  closed  the  abdomen.  The  patient  made  an 
excellent  recovery. 

As  I  have  indicated  already,  this  irritation  and  tenesmus  in  the 
bowel  is  very  apt  to  deceive  the  physician  unless  he  considers  most 
carefully  the  history  of  the  case. 

Should  the  pelvic  hematocele  be  seen  later,  when  a  consider- 
able portion  of  blood  is  absorbed,  the  tumour  remaining  may  simulate 


ECTOPIC  PREGNANCY  578 

any  of  the  tumours  connected  with  the  uterus  or  appendages,  but  the 
history  of  the  case  will  usually  clear  matters  up.  The  tumour  is 
peculiarly  fixed,  and  it  seldom  has  the  definite  outline  that  one  finds 
in  a  myoma  or  an  ovarian  growth.  It  most  nearly  resembles  a 
chronic  salpingitis.  In  distinguishing  between  these  two  conditions 
one  must  rely  entirely  on  the  history.  In  salpingitis  there  is  the 
story  of  old-standing  pelvic  and  abdominal  pain  ;  in  hematocele 
there  is  the  history  of  the  condition  dating  back  to  some  comparatively 
recent  acute  abdominal  illness. 

Treatment. — In  dealing  with  a  pelvic  hematocele  most  gynecolo- 
gists are  in  favour  of  operation,  but  there  are  still  a  few  who 
recommend  the  expectant  treatment.  This  expectant  treatment  con- 
sists of  absolute  rest  in  bed,  fomentations,  etc.,  and,  later,  douching 
and  the  administration  of  syrup  of  the  iodide  of  iron,  all  with  the 
object  of  favouring  absorption.  The  treatment  is  a  very  prolonged 
one  and  the  recovery  most  protracted,  two  or  three  months  sometimes 
passing  before  the  blood  is  completely  absorbed.  In  a  number  of 
cases  it  has  proved  quite  successful,  but  in  others  adhesions  between 
uterus,  intestines,  tubes,  and  ovaries  have  followed,  and  the  ultimate 
health  of  the  patient  has  been  far  from  satisfactory.  In  a  few  cases 
the  hematocele  has  been  infected,  and  an  abscess  has  formed,  with 
all  its  dangers.  In  this  connexion  Bell1  has  given  a  very  interesting 
comparison  between  the  results  from  the  expectant  and  the  active 
treatment.  He  takes  the  results  of  Champneys,  a  strong  advocate 
of  expectancy,  and  compares  them  with  those  of  Cullingworth,  Tait, 
and  Fairbairn,  in  St.  Thomas's  Hospital.  He  comes  to  the  following 
conclusion  :  '  Hence  a  comparison  of  the  two  lines  of  treatment  shows 
that  the  desire  to  avoid  operation  leads  to  a  higher  mortality,  not 
only  in  cases  operated  upon,  but  also  in  the  whole  series  of  cases.' 

If  operation  is  decided  upon,  either  the  vaginal  or  abdominal  route 
may  be  chosen  ;  there  is  much  to  be  said  for  each  of  these  routes. 
By  the  abdominal  route  all  blood-clot  can  be  cleared  away,  and  any 
other  unsatisfactory  state  of  tubes,  ovaries,  and  uterus  ma}'  be 
corrected.  The  disadvantage  of  the  method  is  that  the  hematocele, 
shut  off  by  adhesions  between  the  intestines,  is  opened  into  through 
the  general  abdominal  cavity. 

By  opening  through  the  vaginal  vault,  blood-clot  may  be  removed 
without  opening  into  the  general  peritoneal  cavity.  Whichever  route 
is  chosen,  the  cavity  should  be  drained  with  iodoform  gauze  brought 
out  through  the  vagina. 

Personally,  I  prefer  the  abdominal  route,  unless  suppuration  has 
occurred  in  the  sac,  and  I  do  so  because  I  think  it  advisable  in  all 

1  Op.  cit. 


:.7  1 


OPEBATtt  E  .MlhWII  H;\ 


-  to  examine  the  tubes  and  ovarii'.-,  and  to  suspend  tin-  ut.-rn- 
the  abdominal  wall,  so  as  to  prevent  it  becoming  fixed  in  a  position  of 
retroflexion. 

Pregnancy  in  a  Rudimentary  Horn. 

Pregnancy  in  a  rudimentary  horn,  often  referred  to  as  cornual 
pregnancy,  although  the  latter  term  is  a  little  misleading,  is  a 
condition  which  1  have  already  hriefly  referred  to  in  Chapter  XX. 
(Dystocia  the  liesult  of  Abnormalities  affecting  the  Parturient  (anal). 
I  must  here,  however,  consider  the  complication  a  little  more  fully,  for 
clinically  it  resembles  extra-uterine  pregnancy  in  many  of  its  details. 


Fig.  266. — Pregnancy  in  a  Rudimentary  Horn.     (Diagrammatic.) 

The  illustration  (Fig.  266)  indicates  at  a  glance  the  relationship  of  the 
rudimentary  to  the  normal  uterine  horn.  The  connexion  between  the 
two  horns  is  by  a  fibro-muscular  band  of  from  2  to  <*>  centimetres. 
This  band  is  usually  attached  to  the  normal  horn  about  the  level  of 
the  internal  os,  although  its  lower  margin  may  be  as  low  as  the 
os  externum.  In  the  great  majority  of  cases  no  canal  is  found,  and  in 
many  when  it  exists  it  is  incomplete.  Werth1  found  in  his  hundred 
collected  cases  a  canal  in  nineteen,  but  only  in  two  was  there  an 
opening  into  both  parts  of  the  uterus.  It  is  possible  that  occasionally 
the  canal  becomes  closed  during  pregnancy.  As  there  is  so  seldom  b 
canal,  impregnation  occurs  usually  by  the  spermatozoa  passing  through 
1  Winckel's  '  Handbuch  der  Geburtshulfe,'  1904,  Bd.  ii..  Teil  ii.,  p.  998. 


ECTOPIC  PREGNANCY  575 

the  healthy  half  of  the  uterus  and  tube,  and  impregnating  an  ovum 
which  has  been  shed  from  the  ovary  connected  with  the  rudimentary 
horn.  In  some  few  cases,  however,  an  ovum  from  the  other  ovary 
has  been  impregnated,  as  the  corpus  luteum  was  discovered  in  the 
ovary  connected  with  the  normal  horn. 

The  course  of  pregnancy  in  a  rudimentary  horn  is  variable.  In  a 
large  proportion  of  cases  rupture  occurs  because  of  the  poorly-developed 
muscular  and  mucous  coats.  The  trophoblast,  meeting  with  little 
resistance,  burrows  into  the  wall  and  erodes  it.  This  will  be  seen  in 
the  figures  accompanying  a  recent  paper  by  Hoff.1  According  to 
Werth,  rupture  occurred  in  forty-five  of  his  hundred  collected  cases. 
The  fourth  and  fifth  months  are  the  most  usual  time  for  this  occurrence, 
but  quite  a  number  occurred  earlier,  and  a  few  even  later  than  that 
time.  In  the  cases  in  which  rupture  occurs  it  will  be  found  that 
the  clinical  features  usually  resemble  those  found  in  extra-uterine 
pregnancy,  described  under  Group  2 — recurrent  attacks  of  abdominal 
pain,  tenderness,  faintings,  often  vaginal  discharge,  and  expulsion  of 
the  decidual  from  the  normal  uterine  horn.  In  some  cases  the 
rupture  and  collapse  occur  suddenly  without  any  premonitory 
symptoms,  such  cases  being  comparable  to  those  belonging  to 
Group  1. 

In  quite  a  number  of  cases,  however,  the  pregnancy  continues  to 
term.  In  this  country  Galabin,2  Targett,3  Murdoch  Cameron,4  Bland- 
Sutton,5  and  Roberts6  have  recorded  such  cases,  and  there  are  a 
considerable  number  recorded  by  different  foreign  writers.  In  these 
cases  the  striking  clinical  fact  is  that  there  were  so  generally  attacks 
of  abdominal  pain  and  vaginal  haemorrhage,  etc.,  during  pregnancy. 
Late  in  pregnancy,  often  about  the  time  labour  was  expected,  a 
'  spurious  labour  '  occurred  in  many  of  the  cases. 

A  foetus  retained  after  its  death  may  undergo  all  the  changes 
that  have  been  described  already  in  connexion  with  extra-uterine 
pregnancy. 

Of  the  rare  complications  which  are  associated  with  a  gravid 
rudimentary  horn  may  be  mentioned  torsion  of  the  pedicle,  prolapse 
of  the  tumour  behind  the  uterus,  and  infection  of  the  sac. 

The  condition  is  theoretically  not  difficult  of  diagnosis,  but  in 
practice  it  is  comparatively  seldom  that  it  is  fully  appreciated  before 
the  abdomen  is  opened.  Extra-uterine  pregnancy  is  the  usual 
diagnosis.     Targett,  Bland- Sutton,  and  a  few  others,  recognized  the 

1  Archie  f.  Gyn.,  Bd.  Ixxx.,  Heft  2,  p.  352. 

2  Trans.  Lond.  Obst.  Soc,  vol.  xxxvii.,  p.  225. 

3  Ibid.,  vol.  xlii.,  p.  276. 

4  Jouni.  Obst.  and  Gyn.  Brit.  J'Ju/jdrc.  vol.  i.,  p.  67. 

5  Trans.  Lond.  Obst.  Soc,  vol.  xliv.,  p.  316. 

11  Jouni.  Obst.  and  Gyn.  Brit.  Empire,  December,  1905. 


576  OPERATIVE  MIDWIFERY 

condition  exactly  before  operation.  The  position  of  the  round 
ligament  and  the  separation  of  the  tumour  from  the  uterus  are 
important  features,  especially  in  the  early  months,  but  later  the  sac 
is  so  large  that  these  landmarks  are  often  difficult  to  distinguish. 
In  the  early  months  an  interstitial  ectopic  pregnancy  is  somewhat 
similar,  only  in  that  condition  the  tumour  and  uterus  form  one  body. 
Later  in  pregnancy,  when  the  gravid  horn  is  of  large  size,  the  latter 
may  be  mistaken  for  the  pregnant  uterus,  and  the  non-gravid  normal 
horn  mistaken  for  a  myoma  or  an  ovarian  tumour.  In  such  cases  of 
difficulty  the  uterine  sound,  employed  with  great  caution,  may  be  of 
assistance  in  coming  to  a  conclusion  regarding  the  exact  nature  of  the 
condition. 

The  treatment  of  this  condition  is  to  remove  the  gravid  horn.  In 
two  cases  recorded  by  Doran1  normal  pregnancy  has  occurred  in  the 
horn  left.  In  most  cases  the  removal  of  the  gravid  horn  is  not 
difficult.  The  ovarian  vessels  are  ligatured  in  the  infundibulo-pelvic 
ligament,  and  then  the  band  connecting  the  horn  with  the  other  half 
of  the  uterus  is  secured.  Special  care  must  be  taken  in  ligating  the 
latter,  for  there  may  be  veiy  free  bleeding  if  it  is  not  carefully  tied. 

But  not  infrequently  adhesions  to  the  surrounding  parts  exist,  so 
that,  as  in  Targett's  and  Bland- Sutton's  cases,  considerable  difficulty 
may  be  experienced  in  separating  them  and  in  securing  all  the  bleed- 
ing points. 

It  may  occasionally  happen  that  the  association  of  the  sac  and  the 
other  horn  of  the  uterus  is  so  intimate  that  total  extirpation  is  deemed 
advisable. 

Should  it  be  suspected  that  the  contents  of  the  sac  are  septic,  and 
should  it  be  found,  when  the  abdomen  is  opened,  that  the  sac  wall  lias 
very  intimate  connexions  with  the  surrounding  structures,  it  is  well 
not  to  try  and  extirpate  the  sac,  but  to  open  it  from  the  vagina  and 
empty  and  drain  it  for  some  time.     The  sac  may  be  removed  later. 

If  it  is  quite  impossible  to  remove  the  sac — a  very  rare  con- 
tingency to  judge  by  recorded  cases — the  sac  may  be  emptied  from 
the  abdomen,  and  the  Fallopian  tube  belonging  to  the  rudimentary 
horn  removed,  or  divided  and  ligatured,  so  as  to  prevent  the  horn 
again  becoming  gravid.  Cameron  pursued  this  course  in  his  case. 
He  took  the  further  precaution  of  packing  the  cavity,  and  bringing 
out  the  gauze  through  the  vaginal  vault.2 

1  Journ.  Obst.  and  Gyn.  Brit.  Umpire,  June,  1906,  vol.  ix..  p.  443. 

-  As  it  would  serve  no  practical  purpose,  I  have  not  considered  eases  of  repeated 
ectopic  pregnancy,  pregnancy  in  both  tubes,  plural  pregnancy  in  one  tube,  and  of 
coexisting  tubal  and  uterine  pregnancy.  I  nave,  however,  detailed  in  connexion 
with  rny  case  of  ovarian  pregnancy  this  most  rare  condition — a  coexisting  ovarian 
and  uterine  pregnancy. 


CHAPTER  XXXIII 
PLACENTA  PREVIA— ACCIDENTAL  HEMORRHAGE 

By  placenta  previa  is  meant  an  implantation  of  part  of  the  placenta 
over  the  lower  uterine  segment.  The  complication  is  very  serious,  as, 
owing  to  the  situation,  separation  of  it  must  take  place  before  the 
child  is  born.  This  fact  led  Rigby  to  term  the  bleeding  that  occurs 
'  unavoidable  haemorrhage.' 

Until  Portal  in  1685,  but  more  especially  Schacher  in  1709,  clearly 
described  the  anatomical  relationship  of  placenta  to  uterus,  it  was 
believed  that  the  condition  was  produced  by  separation  and  prolapse 
of  the  placenta.  Schacher  demonstrated,  on  the  dead  body  of  a 
woman  with  placenta  previa,  the  exact  relationship  of  the  placenta  to 
the  uterus.  Since  then  the  teaching  has  been  that  the  condition 
arises  from  the  ovum  becoming  attached  low  down,  and,  as  it  grows, 
coming  to  cover  the  os  or  projects  down  towards  it.  The  illustration 
(Fig.  267),  from  a  specimen  of  "William  Hunter's  in  the  Hunterian 
Museum,  shows  this  low  implantation  very  well.  It  is  generally 
supposed  that  this  low  implantation  is  the  result  of  the  uterine  cavity 
being  enlarged,  and  the  endometrium  being  the  seat  Of  an  old- 
standing  inflammation.  In  support  of  such  a  view  there  is  the  fact 
that  the  complication  is  found  to  occur  more  frequently  in  multiparas 
than  in  priniipare,  and  that  in  many  cases  of  the  complication  a 
history  of  old-standing  uterine  trouble  may  be  elicited. 

In  the  Glasgow  Maternity  Hospital  the  proportion  of  primipare 
and  multiparas  was  1  to  26 ;  in  Strassmann's1  recent  figures  it  was 
1  to  5.  The  tendency  to  placenta  previa  increases  with  each  pregnancy, 
and  especially  is  it  liable  to  occur  when  the  pregnancies  occur  in 
rapid  succession.  It  has  also  been  suggested  that  the  low  implanta- 
tion may  sometimes  be  the  result  of  low  implantation  of  the  tubes,  or 
of  impregnation  occurring  when  the  ovum  is  just  about  to  escape 
from  the  uterus.  As,  however,  we  do  not  yet  know  where  the 
meeting-place  of  the  ovum  and  spermatozoa  normally  is,  these  sugges- 

1  Arcliiv  f.  Gijn.,  Bd.  lxvii..  p.  112. 

577  37 


578 


OPERATIVE  MIDWIFERY 


t  ions  are  pure  speculations.     So  also  is  the  view  that  the  coverin 
the  ovum  is  altered,  and  that  it  doc-  not  ingraft  itself  until  it  reaches 
the  lower  part  of  the  uterus. 

Occasionally  the  placenta  becomes  previa  purely  by  reason  of  its 
size.  Thus,  placenta  preevia  occurs  oftener  with  plural  than  with 
Bingle  pregnancies.  In  my  forty  cases  it  occurred  twice.  Strassmann 
in  281  cases  found  it  fifteen  times. 


Fig.  207. — Implantation  of  the  Ovum  over  Os  Internum. 
Glasgow  University.) 


(Hunterian  Museum, 


But  one  not  infrequently  finds  an  unusually  large  placenta  apart 
altogether  from  plural  pregnancy.  Strassmann  explains  this  by 
saying  that  there  is  a  defective  blood-supply,  and  in  consequence  the 
placenta  must  become  large  to  cope  with  the  demands  of  the  foetus; 
but  does  this  explanation  not  beg  the  question  ? 

In  recent  times  the  theory  advanced  by  Hofmeier1  and  confirmed 

1  'Die  Menschliche  Placenta.'  Wiesbaden,  1890. 


PLACENTA  PILEYIA— ACCIDENTAL  HAEMORRHAGE     579 

by  Kaltenbach,  that  the  condition  arises  from  a  development  of 
placenta  from  the  '  decidua  reflcxa,'  which,  as  pregnancy  advances, 
comes  to  cover  the  os  internum,  has  met  with  considerable  support. 
There  are  now  a  sufficient  number  of  specimens  confirming  this 
view.  In  most  cases,  however,  a  low  implantation  is  present  from 
the  first.  This  is  apparent  in  Webster's1  specimens,  which  were 
shown  in  support  of  Hofmeier's  and  Kaltenbach's  views. 

The  frequency  of  placenta  previa  in  the  Glasgow  Maternity 
Hospital  has  been  1  in  300  cases ;  but  naturally  the  percentage  is 
higher  in  hospital  practice,  for  the  complicated  cases  tend  to 
gravitate  there.     Hofmeier  puts  it  at  1  in  500  to  600;  Strassmann,'- 


Fig.  268. — Showing  the  Different  Varieties  of  Placenta  Pnevia. 


for  the  Berlin  Charite,  found  it  1  in  220  for  the  Klinik  and  1  in  300 
for  the  Poliklinik. 

The  extent  of  the  implantation  varies  greatly,  so  that  it  is 
customary  to  divide  examples  of  this  complication  into  a  '  central  or 
complete,''  a  '  marginal '  and  a  'lateral'  variety,  according  as  the  placenta 
completely  covers  the  os  internum,  reaches  up  to  its  margin,  or  dips 
into  the  lower  uterine  segment.  This  will  be  clearly  understood 
from  the  illustration  (Fig.  268).  In  almost  all  cases  of  central 
implantation  the  placenta  is  attached  more  to  one  side  of  the  uterus 
than  the  other  ;  very  rarely  does  the  middle  of  the  placenta  correspond 
exactly  to  the  os  internum  (Fig.  269).  Again,  as  dilatation  occurs  in 
a  case  where  only  a  small  portion  of  the  placenta  covers  the  os,  this 

1  Webster,  '  Text-book  of  Obstetrics,'  1903,  p.  543. 
-  Wrnckel's  '  Handbuch,'  Bd.  ii.,  Teil  ii.,  p.  1202. 


iso 


OPERATIVE  MIDWIFERY 


Fig.  269. — Complete  or  Central  Placenta  Pnevia. 

(Photographed  from  Van  Rymsdyk's  drawing  in  the  Hunterian  Museum,  Glasj 

l  Iniversity. 

small  part  becomes  separated,  and  feels  to  the  examining  finger  like 
a  tongue  hanging  over,  or  projecting  into,  the  cervix.     It  was  origin- 


PLACENTA  PREVIA— ACCIDENTAL  HAEMORRHAGE     581 

ally,  nevertheless,  an  example  of  the  central  or  complete  variety. 
There  are  objections  to  all  classifications,  but,  as  it  is  almost 
necessary  to  have  a  classification,  I  think  the  one  given  is  as  good  as 
any  other. 

Clinical  Features  and  Diagnosis. 

The  condition  first  makes  itself  known  by  haemorrhage.  The 
bleeding  may  occur  without  warning  when  the  woman  is  at  rest, 
although  it  often  follows  straining  efforts,  such  as  straining  at  stool, 
lifting  weights,  or  after  severe  fits  of  coughing,  sneezing,  etc.  As  a 
rule,  the  first  hemorrhage  occurs  during  the  last  ten  weeks  of 
pregnancy,  but  sometimes  not  until  term.  Occasionally  it  manifests 
itself  very  early,  as  can  be  judged  from  the  accompanying  table. 

Table  to  show  Time  of  Onset  of  Hemorrhage  in  Placenta  Pr.eyia. 


Mouth. 

Pinard. 

Dorantk  (Klinik  Chrobak). 

Cases. 

Cases. 

First      ... 

25 

4 

Second... 

11 

4 

Third    ... 

18 

5 

Fourth... 

7 

4 

Fifth     ... 

10 

5 

Sixth     ... 

27 

14 

Seventh 

23 

17 

Eighth... 

20 

40 

Ninth    ... 

— 

40 

Tenth    ... 

— 

21 

Term     ... 

11 

43 

Commencement  of  labour 
Total 

17 

— 

169 

197 

Not  a  few  abortions  are  the  result  of  the  condition.  As  regards 
this,  Strassmann  gives  the  following  figures :  Abortion,  18  per  cent.  ; 
premature  birth,  42  per  cent. ;  full-time  birth,  39  per  cent. 

The  blood  comes,  of  course,  from  the  portion  of  the  uterine 
surface  from  which  the  placenta  is  detached,  and,  to  a  very  slight 
extent,  from  the  separated  portion  of  placenta.  In  addition,  on  one 
or  two  occasions  very  profuse  bleeding  has  occurred  from  rupture 
of  the  circular  sinus  of  the  placenta  (Fig.  270).  Matthews  Duncan  x 
refers  to  this  specially.  Budin2  has  reported  several  cases  of  this 
nature. 


1  'Mechanism  of  Natural  and  Morbid  Parturition,'  1875,  p.  387. 

2  Societe  d'Obstet.  et  Gyn.,  June,  1893. 


J82 


OPERATIC  E  MIDWIFER1 


Beemorrhage  occurring  during  Labour  is  easily  understood;    the 

os  as  it  dilates,  and  the  lower  uterine  segment  as  it  develops,  bring 
about  the  separation  of   the  placenta.      When  hemorrhage  occurs 
during  pregnancy,  the  explanation  is  that  the  bleeding  is  produced 
by  the  same  conditions  that  bring  about  'accidental  htemorrha 
That  this  is  probably  the  correct  explanation  is  supported   by  the 


Fig.  270. — Showing  Portion  of  Uterine  "Wall  and  Attached  Placenta. 

The  circular  sinus  is  very  distinctly  seen.     (Drawing  from  a  specimen  in  the  Hunteriau 
Museum,  Glasgow  University.) 

fact  that  both  varieties  of  hemorrhage  result  from  similar  diseased 
conditions  of  the  uterus.  In  this  connexion  one  must  not  forget 
that,  besides  the  active  and  rapid  development  of  the  lower  uterine 
segment  which  occurs  during  labour,  there  is  a  slow  increase  of  the 
segment  ^in  the  later  weeks  of  pregnancy.  Yon  Franque  found 
the  upper  limit  of  the  lower  segment  from  the  second  to  the  fourth 
months  2*5  centimetres,  from  the  fifth  to  the  sixth  months  4  centi- 


PLACENTA  PR/EVIA— ACCIDENTAL  HAEMORRHAGE    583 

metres,  and  from  the  seventh  to  the  tenth  months  6  centimetres, 
above  the  os  internum. 

At  the  first  attack  the  bleeding  is  often  slight,  so  that  assistance 
is  unfortunately  not  requested  until  several  attacks  have  occurred. 
Recurrent  attacks  of  haemorrhage,  becoming  gradually  more  severe,  is 
the  usual  history. 

Although  one  would  expect  the  central  variety  to  be  associated  with 
earlier  and  more  severe  hemorrhages  than  the  lateral,  this  is  not 
always  so.  On  several  occasions  I  have  observed  cases  of  central 
attachment  where  term  was  reached,  and  no  bleeding  occurred  until 
labour  actually  commenced.  This  has  been  frequently  remarked. 
Naturally,  in  cases  of  the  lateral  variety  there  is  often  no  bleeding 
until  labour  occurs. 

In  some  few  cases  of  central  attachment  the  placenta  has  been 
expelled  before  the  child,  and  in  one  or  two  the  child  has  been  born 
through  the  placenta.  These  are  extremely  rare  occurrences,  for 
usually  uterine  action  is  not  very  strong,  and  the  profuse  bleeding 
leads  to  collapse  of  the  woman  and  inhibition  of  the  uterine 
contractions. 

Placenta  previa  is  not,  as  a  rule,  difficult  of  diagnosis ;  indeed, 
the  only  other  condition  which  really  resembles  it  is  '  accidental 
haemorrhage.'  It  should  always  be  suspected  with  any  haemorrhage 
during  pregnancy,  especially  during  the  later  weeks.  On  two 
occasions  I  have  been  able,  by  abdominal  palpation,  to  locate  a 
placenta  situated  on  the  anterolateral  wall.  The  head  in  the  lower 
pole  of  the  uterus  could  be  made  out  on  one  side,  but  on  the  other 
was  obscurely  felt  as  if  through  a  doughy  swelling.  Palpation  of  the 
placenta,  however,  is  seldom  possible,  and  it  is  questionable  in  these 
two  cases  if  I  would  have  recognized  the  abnormal  position  of  the 
placenta  had  my  attention  not  been  arrested  by  the  hemorrhage. 

In  coming  to  a  diagnosis  one  must  depend  on  the  vaginal  examina- 
tion, and  actually  feel  the  placenta  with  the  examining  fingers.  If 
one  feels  the  placenta  one  calls  the  condition  placenta  previa,  if  one 
does  not  feel  it  one  diagnoses  it  '  accidental  hemorrhage.'  If  the  os 
is  sufficiently  dilated  to  allow  of  the  finger  being  passed  through — 
and  that  is  usually  the  case — the  placenta  is  easily  recognized,  for 
almost  the  only  thing  that  can  be  mistaken  for  it  is  blood-clot.  The 
latter  is  soft,  smooth,  and  breaks  up  under  the  pressure  of  the  finger, 
while  the  placenta  feels  firm  and  rough.  I  once  saw  a  case  of 
hydatidiform  mole,  in  which  the  ragged  mass,  which  was  felt  through 
the  cervix  with  the  tip  of  the  examining  finger,  exactly  resembled  a 
placenta.  I  could  also  conceive  of  a  submucous  myoma  such  as  the 
one  figured  on  page  135  resembling  the  placenta.     The  cases  in  which 


:,si  OPERATIVE  MII)\\ll-'i:i;V 

difficulty  is  found  are  the  lateral  forms,  for  sometimes,  with  them, 
only  a  very  small  portion  of  the  placenta  dips  into  the  lower  uterine 
segment,  and  cannot  he  reached  by  the  examining  finger  unless  the 
hand  is  introduced  into  the  vagina  and  the  linger  is  pushed  well  into 
the  uterus.  Not  a  few  of  these  cases  are  never  recognized  :  bleeding 
occurs,  but  with  the  separation  of  the  small  portion  of  the  placenta 
attached  to  the  lower  segment  it  soon  ceases,  and  the  child  is  born.  Ij 
the  membranes  are  examined  after  birth,  it  will  bt  found  that  the  rent  is 
close  to  the  margin  of  the  placenta. 

It  is  generally  stated  that  the  vault  of  the  vagina  feels  boggy,  that 
there  is  difficulty  in  making  out  the  presenting  part  through  the 
placenta,  and  that  ballottement  is  more  difficult  to  appreciate.  In 
cases  of  central  implantation  all  that  is  quite  true ;  but  in  many 
cases  of  lateral  and  marginal  implantation  these  features  are  not 
apparent ;  it  is  only  by  getting  a  ringer  in  through  the  os  internum 
and  feeling  a  portion  of  placenta  that  one  can  make  sure  of  the 
condition. 

The  degree  of  collapse  is  proportionate  to  the  extent  of  the 
bleeding.  The  symptoms  of  such  a  condition  are  small,  rapid  pulse, 
clammy  sweats,  with,  in  extreme  cases,  dimness  of  vision,  air  hunger, 
faintings,  convulsions,  etc. 

I  have  already  said  the  first  attack  of  bleeding  is  usually  not 
excessive  ;  indeed,  so  slight  is  it  sometimes  that  the  woman  does  not 
give  any  information  regarding  it.  But  there  are  many  exceptions 
to  this  rule,  and  Edgar1  has  reported  a  case  where  death  followed  the 
first  attack  of  haemorrhage  at  the  fourth  month  of  pregnancy. 

Prognosis  for  Mother  and  Child. 

The  prognosis  for  both  mother  and  child  is  serious,  and  is  most 
serious  with  the  central  variety.  As  regards  the  mother,  in  the 
Maternity  Hospital  our  mortality  has  been  about  10  per  cent,  for 
some  years.  If  all  care  is  taken  against  septic  infection,  and  the 
delivery  of  the  child  is  not  unreasonably  hurried,  the  mortality  should 
not  rise  above  8  per  cent.  Amongst  the  very  poor,  however,  where 
the  surroundings  are  unfavourable  for  operating,  and  where  the 
women  are  ignorant  and  delay  sending  for  assistance,  and  are  first 
of  all  attended  by  dirty  '  handy-women,'  the  mortality  will  always  be 
greater.  But  apart  from  the  actual  mortality,  the  morbidity  is 
naturally  high  ;  tears  of  the  cervix,  cellulitis,  and  later  phlegmasia 
alba  dolens,  are  not  infrequent,  while  profound  anaemia  and  general 
debility  are  occasional  late  complications. 

1  '  Practice  of  Obstetrics,'  1903,  p.  230. 


PLACENTA  PEiEVIA— ACCIDENTAL  H/EMOKRHAGB     585 

As  regards  the  children,  the  results  are  very  much  more  unfavour- 
able. In  great  part  this  is  due  to  the  fact  that  the  children  are  born 
prematurely.  Taking  my  cases,  this  was  so  in  fully  60  per  cent. 
The  method  of  treatment  employed  is  another  most  important  factor 
in  the  prognosis.  Next  to  the  age  of  the  fcetus  the  foetal  mortality  is 
most  affected  by  the  treatment  employed.  In  this  connexion  we 
shall  see  that  the  lives  of  mother  and  child  are  often  antagonistic. 
Take,  for  example,  accouchement  force  and  version.  The  former  gives 
the  best  fcetal  results,  but  the  worst  maternal ;  while  the  latter  gives 
better  maternal  results,  but  worse  foetal.  With  this  complication, 
however,  we  must  not  be  too  concerned  about  the  child.  The  child 
must  always  be  given  proper  consideration  if  it  is  mature,  but  we 
must  never  risk  the  mother's  life  unduly,  especially  if  the  child  is 
premature. 

The  outlook  is  infinitely  more  serious  for  the  child  with  a  central 
than  with  a  marginal  or  lateral  variety,  for  with  the  former  so 
much  of  the  placenta  becomes  separated  in  the  progress  of  the 
delivery. 

Treatment. 

It  is  interesting  to  remember  that  it  was  in  this  complication 
Guillemeau  recommended  podalic  version,  and  that  by  such  a 
treatment  he  saved  the  daughter  of  Ambrose  Pare,  the  master  who 
had  taught  him  the  new  method  of  turning.  This  was  the  first  really 
scientific  treatment  of  the  condition,  and  it  was  followed  and  amplified 
by  Mauriceau  and  others.  But  accouchement  force  fell  into  disfavour, 
for  the  results  were  not  satisfactory,  and  there  was  a  return  to  the 
old  treatment  of  removing  the  placenta. 

Gradually  it  came  to  be  appreciated  that  rupture  of  the  membranes 
or  version  without  forcible  extraction  was  sufficient  to  arrest  the 
bleeding.  As  regards  the  treatment  by  simply  rupturing  the  mem- 
branes, this  was  recommended  by  Siegemundin,1  who  was  born  about 
100  years  before  Puzos,  so  that  the  latter's  claim  to  priority  cannot  be 
admitted. 

The  most  important  advance  in  the  treatment  of  this  condition 
resulted  from  the  introduction  of  bipolar  version  by  Braxton  Hicks 
some  fifty  years  ago.  By  this  method  forcible  dilatation  of  the 
cervix  prior  to  turning,  with  all  its  dangers,  became  unnecessary. 
Of  much  less  importance  was  the  introduction  of  hydrostatic  dilators. 

But  even  in  a  brief  consideration  of  the  treatment  of  placenta 
praevia,  we  must  never  forget  the  great  service  rendered  by  Barnes 

1  Siebold,  '  Versuch  einer  Geschichte  der  Geburtshiilfe,'  Bd.  ii.,  p.  203,  Berlin, 
1845. 


586  OPEKATIVE  MIDWIFERY 

who  recommended  partial  separation  of  the  placenta,  separation  from 
what  he  termed  the  '  dangerous  zone,'  which  later  investigations  have 
proved  to  be  the  lower  uterine  segment.  Neither  should  we  forget  the 
extraordinary  mistake  made  by  Sir  -lames  V.  Simpson,  of  believing 
that  the  blood  came  from  the  separated  placenta,  and  that,  con- 
sequently, the  treatment  for  the  condition  was  to  remove  the 
placenta.1 

Before  Onset  of  Labour. — In  considering  the  modern  treatment 
of  placenta  pr.evia,  the  first  question  that  naturally  arises  is  that  of 
expectant  treatment.  Is  one  justified  in  temporizing  when  one  kn 
one  is  dealing  with  a  case  of  placenta  prsevia  ?  Personally,  I  have  no 
sympathy  with  such  a  treatment  in  private  practice,  for  I  have 
repeatedly  seen  how  unsatisfactory,  dangerous,  and  even  fatal  it  may 
be.  Only  if  a  skilled  medical  attendant  is  living  under  the  same 
roof,  and  in  constant  attendance  should  such  treatment  be  considered, 
and  even  then  I  am  not  in  favour  of  it,  except  in  very  particular  cases. 
When  a  placenta  praevia  has  been  diagnosed,  the  uterus  should  be 
emptied.  I  am  quite  aware  others,  including  Pinard  and  mam- 
distinguished  obstetricians,  take  up  a  different  position,  and  prescribe 
rest,  sedatives,  and  hot  douches  until  the  child  is  viable. 

Having  considered  the  question  of  temporizing,  and  believing  that 
the  only  safety  to  the  mother  is  in  emptying  the  uterus,  let  us 
consider  the  means  at  our  disposal  for  bringing  about  the  delivery  of 
the  child.  Xow,  it  is  at  once  apparent  that  the  ease  or  difficulty  with 
which  this  can  be  accomplished  will  depend  largely  upon  the  condition 
of  the  cervix,  and  whether  or  not  labour  is  in  progress.  At  present, 
and,  indeed,  for  a  quarter  of  a  century,  the  routine  treatment  in  this, 
as  in  many  other  countries,  has  been  the  vaginal  tampon  (Fig.  271), 
when  the  cervix  is  closed  and  bipolar  version  after  the  manner  of 
Braxton  Hicks,  whenever  the  cervix  is  sufficiently  dilated.  For  many 
years  I  have  employed  these  methods  of  treatment  in  private  and 
hospital  practice,  and  upon  the  whole  I  have  been  well  satisfied  with 
the  results. 

At  the  present  time  many  obstetricians  in  England,  Germany, 
France,  Italy,  etc.,  are  opposed  to  the  tampon,  as  they  believe  it 
possesses  many  disadvantages.  In  the  first  place,  they  say  it  does 
not  always  arrest  the  bleeding,  although  they  admit  that  it  does  so 
usually  if  the  membranes  are  still  unruptured.  They  object  to  it. 
in  the  second  place,  because  it  does  not  always  bring  on  labour,  and 
so  has  to  be  repeated ;  and,  in  the  third  place,  because  there  is  a 
considerable  risk  of  infection,  no  matter  how  carefully  it  is  employed. 
Thej'  would  make  use  of  the  tampon  only  in  cases  of  emergency,  as, 

1  '  Obstetric  Works,'  vol.  i.,  p.  68. 


PLACENTA  PB.EVIA— ACCIDENTAL  H.KMOllKHAGE     587 

for  example,  when  preparations  are  not  complete  for  delivery,  or  the 
patient  has  to  be  removed  to  a  hospital  or  nursing-home.  Let  us 
take  a  few  writers  on  the  subject.  Pinard  disapproves  of  it,  and 
states  that  he  gave  up  employing  it  as  far  back  as  1885.  The  late 
Varnier  was  also  opposed  to  it ;   Nagel  and  Strassmann  condemn  it. 


Fig.  271. — Cervical  and  Vaginal  Tampon  in  Placenta  Prsevia. 

But  Herman,  Eden,  Hofmeier,  Edgar,  and  Williams,  recommend  it 
employed  properly.  As  regards  my  own  experience,  1  believe  it  is  the 
best  treatment  when  bleeding  lias  to  be  arrested  before  labour  has  begun, 
and  when  the  cervix  is  not  taken  up;  but  both  cervix  and  vagina  must  be 
plugged  properly. 


OPERATIVE  MIDWIFERY 

What    is   the    alternative   treatment   to   the   tampon    when    the 

cervix    is    undilated '?      There   are   two    courses   one    may    pursue : 

Rupture  of  the  membranes:    (6)    partial  dilatation,  followed    by 

bipolar  version,  or  the  introduction  of  a  Champeth-r  de  Kibes  or  some 

other  metreurynter. 

As  we  have  seen  already,  simple  rupture  of  the  membranes  is  an 
old  method  of  treatment.  Puzos  advocated  it  towards  the  end  of  the 
eighteenth  century,  and  Siegemundin  suggested  it,  if  she  did  not 
practice  it,  nearly  a  century  earlier.  The  objection  usually  raised  to 
the  treatment  is  that  not  infrequently  it  does  not  completely  arrest 
the  haemorrhage ;  and  that  if  it  is  insufficient  and  the  bleeding  con- 
tinues, one  is  very  awkwardly  placed,  for  plugging  is  valueless  after 
rupturing  the  membranes,  and  version  is  difficult  or  impossible,  as 
the  waters  have  drained  away.  Within  recent  years,  however,  the 
introduction  of  the  various  rubber  bags  has  greatly  altered  matters, 
for  supposing  haemorrhage  does  continue  after  rupture  of  the 
membranes,  a  Champetier  de  Ribes  bag  or  some  other  metreurynter 
maj"  be  introduced.1 

Naturally  it  will  be  asked,  Is  the  cervix  ever  so  rigid  that  it  is 
impossible  to  introduce  two  fingers,  perform  version,  or  insert  a 
metreurynter  ?  In  my  experience  it  is  sometimes  most  difficult  to 
get  the  cervix  dilated  sufficiently.  I  admit  such  cases  are  not 
numerous,  for  the  haemorrhage  always  brings  about  a  degree  of 
softening  and  dilatation ;  still,  they  may  be  encountered. 

When  the  Cervix  is  Dilated  or  Dilatable. — When  the  cervix  is 
dilated  or  dilatable  to  the  extent  of  permitting  two  fingers  being 
passed  through  it,  I  feel  convinced  that  the  general  practitioner  will 
be  well  advised  to  continue  the  treatment  which  has  been  most 
favoured  during  the  last  thirty  years — viz.,  version  according  to  the 
manner  of  Braxton  Hicks  (Fig.  272). 

When  the  cervix  is  dilated  to  any  extent,  version  is  an  easy  matter. 
Personally,  I  have  found  it  an  advantage  to  perform  external  version, 
and  then  seize  hold  of  a  foot  when  the  child  has  been  turned.  I 
find  Strassmann  and  several  other  writers  recommend  this.  In  most 
cases  I  have  found  external  version  easy,  but  if  after  one  or  two 
attempts  it  is  impossible,  then  the  ordinary  method  of  bipolar  version 
must  be  employed.  "When  rupturing  the  membranes,  this  should  be 
done  to  the  side  of  the  placenta;    but  in  some  cases  of  central  or 

1  If  labour  has  advanced  considerably  by  the  time  the  patient  comes  under 
treatment,  rupture  of  the  membranes  is  quite  sufficient  if  the  placenta  is  lateral, 
or  even  marginal.  In  such  cases  the  pressure  of  the  head  arrests  the  bleeding. 
Besides,  by  this  treatment  one  will  save  most  children,  for  when  the  os  is  fully 
dilated  one  can,  if  necessary,  deliver  with  forceps. 


PLACENTA  PB/EVIA— ACCIDENTAL  ILEMOBBHAGE     589 

complete  placenta  pnevia  this  is  not  possible,  for  the  edge  cannot  be 
reached.  In  such  cases  the  fingers  should  be  pushed  through  the 
placental  tissues.  The  foot  having  been  seized  and  brought  down  in 
the  manner  described  (p.  55),  a  loop  of  gauze  should  be  attached  to 


Fig.  272. — Bipolar  Version  in  Placenta  Prrevia.     (Bumm.) 


it,  so  that  slight  traction  may  occasionally  be  applied  to  it  should  it 
be  deemed  necessary.  It  is  of  the  greatest  importance  that  no 
attempts  at  hurried  extraction  of  the  child  be  made.  The  child's 
thigh  and  breach  must  be  pushed  through  the  cervix  by  the  uterine 
contractions,   not  dragged   through,  otherwise  serious   laceration    of 


590  OPERATIVE  Mll>\\  Il'KliY 

the  cervix  and  great  difficulty  with  the  arms  and  after-coming  head 
may  result.  Should  the  uterine  contractions  be  feeble  and  infrequent, 
occasional  traction  on  the  limb  may  be  indulged  in,  but  only  with  the 
ohject  of  stimulating  uterine  action. 

By  this  method  the  bleeding,  in  my  experience,  has  always  been 
arrested.  It  is  not  surprising,  therefore,  that  so  many  operators 
favour  this  treatment,  and  that  the  results  obtained  from  it  should 
l)e  so  satisfactory.  In  my  hospital  and  private  practice  during  the 
years  1901  to  1906  I  had  forty  cases  with  a  maternal  mortality  of 
7*5  per  cent.  Nagel1  had  forty-two  consecutive  case-  without  a  death, 
Hofmeier  thirty-seven  cases  with  one  death,  and  there  are  many  others 
showing  a  mortality  of  only  4"5  per  cent,  or  6  per  cent.  Whenever 
attempts  at  dilatation  and  rapid  extraction  are  made  with  the  object  of 
improving  the  fcetal  mortality,  the  maternal  is  at  once  raised,  and 
that  is  the  reason  why  my  results  show  a  higher  death-rate.  This  also 
explains  Klein's  figures  for  the  Chrobak  Klinik  in  Vienna,  where  there 
was  a  maternal  mortality  of  9'4  per  cent.  Olshausen,  Leopold,  and 
Noble,  all  emphasize  this  point,  and  Strassmann,  in  his  most  excellent 
monograph,  shows  by  his  figures  that  extraction  improves  the  prognosis 
for  the  child  by  285  per  cent.,  but  makes  it  worse  for  the  mother  by 
1T-A  per  cent.  As  regards  the  mother,  then,  I  am  convinced  that, 
taking  everything  into  consideration,  bipolar  version  is  the  safe.-t 
and  best  treatment  for  the  general  practitioner.  Strassmann  says  it 
continues  to  be  the  simplest  and  safest,  and  Bumm,2  Zweifel,3  and 
most  English  obstetricians  are  of  the  same  opinion. 

The  disappointing  feature  about  version  is  that  the  fcetal  mortality 
is  so  high. 

Total  Cases  of  Placenta  Pr.eyia  in*  my  Hospital  and  Private  Practice, 
1901-1906— Forty  Cases  in  all. 


Relative  Maternal  Total 

Percentages.  Deaths.  I  •    it  be. 


Foetus 
macerated. 


Central  ...       42  per  cent.         1 i _  _  66  per  cent. 

Marginal        ...       -21         „  proper  5Q        ^  3-75  per  cent. 

Lateral  ...        36         „  1)     cent'  41 

There  were  two  cases  of  twins  ;  in  one  case  both  children  were 
born  alive,  in  the  other  both  were  born  dead.  In  75  per  cent,  of 
cases  bipolar  version  was  the  treatment ;  in  four  C'hampetier  de  Ribes 
bags  were  inserted,  and  in  four  accouchement  force  was  employed. 

1  'Operative  Geburtshiilfe.'  L902. 

-  '  Grundriss  Studium  der  Geburtshiilfe,'  1902,  p.  603. 

3  Munch.  Med.  Woch.,  1907,  Nr.  48. 


PLACENTA  PREVIA— ACCIDENTAL  HEMORRHAGE    59J 

To  all  intents  and  purposes,  therefore,  the  figures  here  given  represent 
the  results  from  bipolar  version.  My  results  in  forty  cases  show  a 
fatal  mortality  of  52  per  cent.  Of  recent  writers  who  favour  version 
may  be  mentioned  Sonnenfeld,1  who  gives  his  foetal  mortality  as 
62  per  cent.,  and  Berger  and  Graf,2  who  give  a  fcetal  mortality  for 
Schauta's  Klinik  in  Vienna  of  54'9  per  cent. 

It  is  owing  to  the  fact  that  the  fcetal  mortality  is  so  very  high — 
not  because  of  the  maternal  mortality,  which  can  hardly  be  improved 
upon — that  other  modes  of  treatment  than  version  have  been  advocated. 
The  first  we  will  consider  is  the  comparatively  recent  treatment  with 
the  metreurynter  (Fig.  273).  It  is  not  of  much  importance  which  of 
the  various  forms  of  this  instrument  is  employed,  but  in  speaking  of 
it  and  describing  how  it  is  introduced  (p.  464)  I  have  indicated  a 
preference  for  the  one  devised  by  Champetier  de  Ribes.  Used  in 
cases  of  placenta  previa,  this  instrument  compresses  the  placenta 
against  the  uterine  wall  and  so  arrests  the  haemorrhage,  and,  at  the 
same  time,  dilates  the  cervix  and  allows  of  the  easy  expulsion  of 
the  child  afterwards.  It  must,  of  course,  be  introduced  after  the 
membranes  are 'ruptured;  for  if,  as  has  sometimes  been  done,  the 
bag  is  pushed  in  against  the  unruptured  membranes,  the  result  must 
be  that  more  of  the  placenta  is  stripped  off.  Zimmermann3  recom- 
mends maintaining  the  membranes  intact ;  I  feel  sure  this  is  unwise. 

As  regards  the  results  from  the  metreurynter,  Hofmeier,  Strass- 
mann,  and  Nagel  are  satisfied  it  has  not  reduced  the  fcetal  mortality  to 
any  very  great  extent,  but  other  equally  distinguished  writers  hold  the 
opposite  view.  Without  doubt  Pinard's  results  are  very  good,  for  with 
rupture  of  the  membranes  and  the  metreurynter  the  foetal  mortality 
was  31  per  cent.  Zimmermann  gives  for  116  cases  a  maternal 
mortality  of  5  per  cent,  and  a  fcetal  of  37  per  cent.,  and  Hannes,4 
for  a  series  of  112  cases,  a  fcetal  mortality  of  30  per  cent.  I  am 
satisfied  that  for  hospital  practice,  or  where  the  conditions  are  favour- 
able in  private  practice,  the  metreurynter  is  suitable,  and  gives  the 
slightly  better  results  as  regards  the  child. 

As  regards  the  dangers  of  this  method  of  treatment  I  need  say 
little.  There  are  all  the  ordinary  dangers  attendant  upon  all  forms 
of  treatment  in  placenta  prrevia — infection,  laceration  of  cervix,  etc. 
Lea,  Braun  von  Fernwald,  and  others,  have  recorded  cases  of  rupture 
of  the  uterus,  and  Strassmann  has  pointed  out  that  after  the  expulsion 
of  the  metreurynter  there  may  be  a  very  profuse  discharge  of  blood. 

1  Monat.  f.  Geb.  u.  Gyn.,  1901,  Bd.  xx.,  p.  1096. 

2  Ibid.,  January,  1907,  Bd.  xxv.,  p.  49. 

3  Ibid.,  1902,  Bd.  xvi.,  p.  37. 

4  Zcnt.f.  Gyn.,  Nr.  3,  1909. 


592 


OPERATIVE  MIDWIFE  I;  Y 


On  several  occasions  the  metreurynter  lias  burst,  but  that  accident 
should  not  happen  if  the  hag  is  tested  beforehand. 

With  the  object  of  lowering  the  fu-tal  mortality  still  farther,  much 
more  active  and  heroic  methods  of  treatment  have  been  suggested 


Fig.  273.— Metreurynter  in  Placenta  Prsevia.     (Bunmi.) 


in  recent  years.  Thus,  forcible  dilatation  of  the  cervix,  either  by 
the  fingers  or  by  metal  dilators,  vaginal  Cesarean  section,  and  even 
the  classical  Cesarean  section  have  been  recommended. 

Piegarding  accouchement  force,  I  very  much  question  the  wisdom 
of  employing  it  in  such  a  condition  as  placenta  prsevia.      And  in 


PLACENTA  PR.EVIA— ACCIDENTAL  HAEMORRHAGE     593 

support  of  this  view  I  would  refer  my  readers  to  the  attitude  of 
Treub  of  Amsterdam,  who,  until  recently,  strongly  recommended 
this  treatment.  Within  the  last  two  years,  however,  he  has 
abandoned  it. 

But  at  the  present  day  there  are  those  who  recommend  vaginal 
and  abdominal  Cesarean  section  for  this  condition. 

Under  no  circumstance  whatever  is  it  conceivable  that  vaginal 
Cesarean  section  is  a  suitable  operation  for  placenta  previa  in  the  later 
months  of  pregnancy.  I  dismiss,  therefore,  this  treatment  without 
doing  more  than  absolutely  condemning  it,  and  in  writing  so  strongly 
I  feel  sure  I  have  the  support  of  all  unprejudiced  obstetricians. 

Abdominal  Cesarean  section,  however,  I  place  in  quite  another 
position.  Suggested  many  years  ago  by  Lawson  Tait,  it  was  received 
with  derision.  In  recent  years,  however,  there  has  been  growing  up 
la  slowly  increasing  body  of  obstetricians  who,  while  not  inclined  to 
advocate  the  treatment,  are  disposed  in  certain  exceptional  cases  to 
adopt  a  less  antagonistic  attitude  towards  it  than  formerly.  I  admit 
I  am  one  of  this  number.  I  have  once  performed  the  operation  for 
placenta  prawia  with  a  successful  result  for  both  mother  and  child,  and 
in  thinking  over  a  large  number  of  cases  of  this  condition  which  have 
been  under  my  care,  I  can  remember  two  others  in  which  it  would  have 
been  the  soundest  treatment. 

It  is  needless  to  say  that  the  cases  of  placenta  previa  in  which 
such  a  radical  operation  as  Cesarean  section  is  contemplated  must  be 
chosen  with  the  very  greatest  care  and  judgment,  and  with  a  mind 
absolutely  unbiased.  Let  us  consider  the  cases  that  possibly  might 
be  suitable  for  this  operation. 

As  we  have  seen,  placenta  previa  has  a  maternal  mortality  of 
8  per  cent.,  and  a  fcetal  mortality  of  50  to  60  per  cent.  The  best 
figures  give  4  per  cent,  and  35  per  cent,  respectively,  and  they  are  as 
low  as  one  can  ever  expect  to  reach  with  the  present  recognized 
methods  of  treatment.  Looking  at  the  fcetal  mortality,  it  must,  I 
think,  be  admitted  that,  provided  the  pregnancy  is  at  or  near  full  time, 
[Cesarean  section  would  undoubtedly  be  better  for  the  child,  for  by 
means  of  it  one  could  make  sure  of  reducing  the  mortality  to  5  per 
cent,  or  7  per  cent,  at  worst.  We  will  dismiss  the  consideration  of 
the  child  for  the  moment,  and  consider  the  mother. 

Taking  the  cases  of  placenta  pmevia  as  a  whole,  better  than  4  per 
cent,  to  8  per  cent,  maternal  mortality  cannot  possibly  be  attained  by 
the  ordinary  methods  (version,  metreurynter,  etc.)  ;  but  are  there  not 
certain  cases  where  that  mortality  of  4  per  cent,  to  8  per  cent.,  which 
is  the  best  average,  cannot  be  attained  by  the  ordinary  recognized 
methods  of  treatment,  when,  in  other  words,  these  treatments  would 

38 


594  OPERATIVE  MIDWIFER1 

coiiitj  to  have  a  higher  mortality  than  (  ;tsarean  section/  The  cases 
which  1  refer  to  are  old  primiparae,  where  the  haemorrhage  occurs  at 
full  time  and  before  labour  has  started,  and  where,  to  judge  by  the 
condition  of  the  parturient  canal  and  the  size  of  the  child,  delivery 
would  be  tedious  and  difficult.  I  pat  the  question  in  connexion  with 
such  cases — Is  it  not  possible  to  get  as  low  a  mortality  from  Cesarean 
section  as  from  the  recognized  treatments  in  such  cases,  provided  the 
women  have  not  been  interfered  with  and  infected'.'  It  will  be 
observed  I  do  not  say  a  '  lower,'  but  '  as  low  "  a  mortality.  If  the 
answer  is  in  the  affirmative,  then  in  such  cases  Caesarean  section  is 
the  right  treatment,  for  there  will  be  an  enormously  larger  number 
of  children  saved. 

Before  leaving  the  subject  of  the  treatment  of  placenta  prsevia,  I 
must  warn  my  readers  to  be  always  prepared  for  post-partum  haemor- 
rhage. This  haemorrhage  is  said  to  occur  because  the  placental  site 
does  not  retract  satisfactorily,  situated  as  it  is  in  a  less  actively 
contractile  portion  of  the  uterus.  In  my  experience  severe  post- 
partum haemorrhage  rarely  follows  this  variety  of  ante-partum 
haemorrhage.  Without  doubt,  if  the  more  rapid  methods  of  emptying 
the  uterus  come  to  be  generally  employed,  post-partum  haemorrhage 
will  be  much  more  common. 

ACCIDENTAL  HEMORRHAGE— ABLATIO  PLACENTAE. 

By  accidental  haemorrhage  is  meant  haemorrhage  that  results  from 
the  partial  or  complete  detachment  of  a  normally-situated  placenta  in 
the  later  weeks  of  pregnancy — say  after  the  child  is  viable.  The 
similar  condition,  prior  to  that  time,  is  abortion. 

The  name  '  accidental  haemorrhage '  was  given  to  the  condition  by 
Rigby,  to  distinguish  it  from  '  unavoidable  haemorrhage,'  the  hemor- 
rhage from  placenta  praevia,  which  we  have  just  considered.  These 
two  terms  have  been  very  generally  employed  since  Rigby's  time.  There 
are,  doubtless,  certain  objections,  particularly  to  '  accidental  ha-mor- 
rhage,'  for  it  might  be,  and  often  is,  understood  as  meaning  ha-morrhage 
of  any  kind  the  result  of  an  accident,  whereas,  as  the  definition  says,  it 
is  haemorrhage  resulting  from  the  detachment  of  a  normally-situated 
placenta.  But  the  terms,  as  far  as  one  can  judge,  are  likely  to 
continue  to  be  employed  ;  at  least,  the  attempt  of  Holmes 1  to  call  the 
condition  of  accidental  hamorrhage  '  ablatio  placenta- '  has  not  met 
with  much  support. 

The  etiology  of  this  complication  may,  with  a  few  reservations,  be 
said  to  be  that  of  abortion.     Frights,  falls,  injuries,  and  diseases  of 

1  Amcr.  Jowrn.  of  Obst.,  1901,  xliv.,  p.  758. 


ACCIDENTAL  HEMORRHAGE— ABLATIO  PLACENT.E    595 

the  various  systems — nervous,  digestive,  etc. — furnish  doubtless  occa- 
sionally causes  for  the  placental  separation ;  but,  without  a  diseased 
condition  of  the  endometrium,  it  is  surprising  how  harmless  such 
disturbances  are. 

Without  the  least  doubt,  the  great  cause  of  'accidental  hemorrhage,' 
as  it  is  the  great  cause  of  abortion,  is  a  chronic  inflammatory  condition 
of  the  uterine  mucosa.  Thus  we  meet  with  the  complication  most 
commonly  in  the  poorer  classes,  in  multipara?,  and  in  those  who  have 
suffered  from  uterine  troubles. 

In  the  severe  cases  of  the  disease  which  I  have  seen,  the  general 
condition  of  the  women  has  been  most  unsatisfactory  ;  very  often  they 
have  been  ailing  for  some  time,  and  many  of  them  have  been  very 
decidedly  anaemic.  I  have  not  often  found  them  the  subjects  of 
chronic  renal  disease,  although,  of  course,  one  often  finds  albumen 
present  in  the  urine.  Winter  and  many  others  have  laid  great  stress 
upon  this.  Personally,  I  am  inclined  to  think  that  the  albuminuria 
often  present  is,  in  many  cases,  the  result  of  the  patient's  general  ill- 
health,  and  is  not  the  cause  of  the  condition. 

How  far  actual  diseases  of  the  placenta  plays  a  part  as  an 
etiological  factor  in  this  complication  it  is  impossible  to  state,  seeing 
that  the  placental  pathology  is  in  such  a  confused  state  at  present. 

Clinical  Features  and  Diagnosis. 

This  all-important  complication  presents  itself  in  two  distinct 
forms,  according  as  the  haemorrhage  escapes  externally  and  is  evident, 
or  becomes  pent  up  inside  the  uterus  between  the  placenta  or  mem- 
branes and  uterine  wall,  when  it  is  spoken  of  as  '  concealed,'  a  term 
given  to  the  condition  by  Baudelocque. 

The  bleeding  is  at  times  so  slight  as  to  be  almost  negligible,  at 
other  times  so  profuse  as  to  place  the  woman's  life  in  the  greatest 
jeopardy.  The  blood  may  come  away  quite  bright  red,  but  if  retained 
for  any  length  of  time  it  is  dark  and  coagulated,  and  sometimes 
is  expelled  in  the  form  of  large,  flat  clots.  If  at  all  profuse,  labour 
comes  on  spontaneously,  or  the  means  employed  to  arrest  the  bleed- 
ing result  in  its  onset.  In  slighter  degrees  one  meets  with  recurrent 
attacks  of  bleeding,  as  in  placenta  previa.  Once  or  twice  I  have  seen 
cases  where,  after  a  moderate  degree  of  active  bleeding,  a  dark 
brownish  discharge  continued  until  labour  came  on  spontaneously 
or  was  induced. 

I  have  said  there  are  two  distinct  varieties ;  I  should  have  added  a 
third  or  a  '  mixed '  variety,  which  includes  a  large  number  of  cases, 
where  the  bleeding  is  partly  external  and  partly  internal. 


596  Ol'KKATIYE  MIDWIFERY 

Both  the  apparent  and  concealed  varieties  are  serious,  but  the 
concealed  is  especially  so,  as  it  is  generally  associated  with  a  more 
diseased  condition  of  the  uterine  wall,  and  is  apt,  from  the  absence  of 
hamorrhage,  to  be  overlooked.  Indeed,  it  is  no  exaggeration  to  say 
that  it  is  one  of  the  most  serious  complications  of  parturition.  As 
the  different  forms  present  features  quite  distinct,  we  shall  consider 
them  separately. 

Apparent  Accidental  Haemorrhage.  —  The  bleeding,  although 
often  following  some  strain,  stress,  or  injurj7,  not  infrequently  comes 
on  without  any  exciting  cause.  The  quantity  of1  the  haemorrhage 
varies.  Sometimes  a  feeling  of  weight  and  tension  in  the  abdomen 
is  complained  of,  but'  until  labour  comes  on  such  discomforts  are 
usually  slight.  Sensations,  such  as  feelings  of  faintness  and  sickness, 
and  evidences  of  anaemia,  such  as  pallor,  rapid  pulse,  etc.,  soon 
supervene  if  the  haemorrhage  is  at  all  profuse. 

A  diagnosis  of  the  condition  is  not  difficult,  although  it  is  by  no 
means  always  easy  to  say  whether  or  not  in  a  particular  case  an 
internal  as  well  as  an  external  bleeding  is  going  on  (Fig.  274).  I 
always  conclude  that  there  is  a  decided  internal  haemorrhage  if  the 
anaemia  and  general  symptoms  are  out  of  proportion  to  the  amount 
of  blood  lost,  and  if  there  is  decided  uterine  tenseness.  It  is  of  the 
greatest  importance  that  these  mixed  forms  should  be  recognized.  In 
my  experience  they  are  very  apt  to  be  disregarded,  for  the  medical 
attendant  is  apt  to  gauge  the  seriousness  of  the  case  by  the  amount 
of  evident  bleeding,  whereas  he  must  always  gauge  it  by  the  general 
condition  of  the  patient  and  the  state  of  the  uterus.  Let  me  give  a 
case  in  illustration  : 

Case  of  Accidental  Hcemorrhage  of  the  '  Mixed'  Type  not  fully  appreciated 
until  the  Parturient  was  extremely  collapsed. — Some  little  time  ago  a  patient, 
a  4-para,  was  admitted  into  my  wards  in  the  Maternity  Hospital  in  a  con- 
dition of  extreme  collapse.  Early  in  the  day  she  had  sent  for  her  medical 
attendant  on  account  of  some  vaginal  haemorrhage  which  alarmed  her.  He, 
seeing  that  the  haemorrhage  was  slight,  advised  absolute  rest  in  bed,  and 
prescribed  some  sedative  to  relieve  the  uterine  pain.  Later  in  the  day 
he  was  again  summoned  to  her  because  of  her  collapsed  condition.  There 
had  been  very  little  external  bleeding  in  the  interval.  The  doctor,  of  course, 
now  diagnosed  the  nature  of  the  condition — concealed  accidental  haemorrhage 
— and  immediately  sent  her  into  hospital. 

So  ill  was  the  patient  when  she  came  under  my  care  that  I  deemed  it 
advisable  to  perform  abdominal  hysterectomy.  She  survived  only  a  few 
hours.  Behind  the  placenta  and  membranes  there  was  a  large  quantity  of 
coagulated  blood,  and  even  the  uterine  wall  contained  in  its  substance 
numerous  and  extensive  lj;emorrha<'es. 


ACCIDENTAL  HEMORRHAGE—  ABLATIO  PLACENTAE    597 

There  is  only  one  other  condition  that  is  likely  to  be  mistaken  for 
apparent  accidental  hemorrhage,  and  that  is  the  hemorrhage  that 
occurs  from  placenta  previa.  Profuse  bleeding  from  polypi,  malignant 
tumours  of  the  cervix,  and  from  torn  vaginal  vessels,  is  extremely 


1 


Fig.  274. — Accidental  Haemorrhage  in  which  the  Bleeding  is  partly  Concealed  aud  partly 

Apparent.     Mixed  Variety. 

rare,  and  may  be  disregarded,  although  quite  recently  my  house- 
surgeon  mistook  a  case  of  concealed  accidental  hemorrhage,  where 
there  was  a  little  external  bleeding  and  the  cervix  was  a  little  thickened, 
for  a  carcinoma  of  the  cervix  complicating  pregnancy.     As  regards 


OPERATIVE  MIDWIFERY 

placenta  previa,  the  placenta   can   be  felt,  as  a  rule,    by  carefully 
Bweeping  the  fingers  round  the  lower  uterine  Begment  inside  the  os 

internum.  Undoubtedly  blood-clots  may  simulate  the  placenta  very 
closely,  but  they  are  smoother  on  the  surface  and  more  friable.  As 
we  have  seen  when  considering  placenta  previa,  a  small  portion 
of  placenta  attached  to  the  lower  segment  may  be  overlooked  very 
easily,  and  there  is  not  the  least  doubt  that  many  cases  of  hemorrhage 
are  of  this  nature.  Fortunately,  treatment  differs  but  little  in  the 
two  conditions,  and  in  carrying  it  out,  as  in  performing  version,  one 
has  an  opportunity  of  making  a  more  exact  diagnosis.  After  delivery 
also,  an  examination  of  the  placenta  and  membranes  may  give 
important  information,  for  in  placenta  previa  the  rupture  in  the 
membranes  will  be  near  the  margin  of  the  placenta,  while  in 
accidental  hemorrhage  it  will  be  some  distance  from  it. 

Concealed  Accidental  Haemorrhage. — Turning  now  to  the  more 
serious  form,  the  '  concealed,'  one  may  find  external  bleeding  entirely 
absent  (Fig.  275).  That,  however,  is  very  uncommon.  In  fifty  cases 
in  the  Maternity  Hospital,  in  the  years  1901  to  1906,  it  was  only  noted 
four  times.  Colclough,1  in  his  analysis  of  eighty-two  cases  in  the 
Rotunda  Hospital,  found  it  in  six  cases,  while  Holmes  in  200  collected 
cases  found  it  fort3T-one  times.  Not  infrequently,  although  there  is 
no  external  bleeding,  there  is  a  serous  discharge  from  the  vagina. 

It  sometimes  happens  that  one  gets  a  history  of  the  woman  having 
had  a  sensation  of  something  having  given  way,  and  this,  especially 
when  external  bleeding  is  absent,  may  give  rise  to  considerable  un- 
certainty as  to  what  exactly  is  the  condition  one  has  to  deal  with. 
Rupture  of  the  uterus  is  the  other  complication  that  most  naturally 
comes  to  one's  mind,  but  rupture  of  the  uterus  during  pregnancy 
or  early  in  labour  is  very  rare,  although  it  does  occur  occasionally. 
Theoretically  the  rapidity  and  extent  of  the  collapse,  the  sudden  onset 
of  pain,  and  the  alteration  in  the  outline  of  the  abdominal  swelling, 
would  lead  one  to  suspect  rupture ;  but,  as  I  shall  show  in 
Chapter  XXXV.,  rupture  may  occur  and  yet  these  symptoms  may 
not  be  present.  In  practice  it  may  occasionally  happen  that  the 
differential  diagnosis  of  the  two  conditions  is  not  easy.  A  sub 
peritoneal  hematoma  referred  to  in  Chapter  XIII.  (p.  208)  may 
also  closely  resemble  concealed  accidental  hemorrhage.  If  the 
hematoma  is  of  any  size,  it  may  be  distinguished  as  a  distinct 
tumour,  although  in  some  cases  that  has  not  been  possible.  The 
all-important  feature  of  concealed  accidental  hcemorrhage  is  tenseness 
and  tenderness  of  the  uterus.  In  addition,  there  is  collapse  out  of  all 
proportion  to  the  amount  of  blood  lost. 

1  Journ.  OW.  ami  Gyn.  Brit.  Empire,  1902,  vol.  ii.,  p.  1">;;. 


ACCIDENTAL  HAEMORRHAGE— ABLATIO  PLACENT/E    599 

The  blood  that  becomes  pent  up  in  the  uterus  collects  between  the 
placenta  and  membranes  and  uterine  wall.  Occasionally  one  finds  the 
whole  placenta  separated  except  at  its  margin,  but  at  other  times,  and 
more  commonly,  some  blood  accumulates  also  behind  the  membranes. 


Fig.  275. — Concealed  Accidental  Haemorrhage. 


Very  rarely  indeed  the  effusion  of  blood  ruptures  into  the  amniotic 
cavity,  and  still  more  rarely  does  the  uterine  wall  give  way. 

As  a  result  of  the  bleeding,  there  are  all  the  symptoms  character- 
istic of  hemorrhage  and  shock — pallor,  faintness,  cold,  clammy  sweats, 
and  small,  rapid  pulse.     The  amount  of  collapse,  however,  is  out  of 


600  OPERATIVE  MIDWIFEBI 

proportion  to  the  quantity  of  blood  effused,  and  is  due,  therefore,  not 
altogether  to  the  anemia,  but  also  to  the  shock  produced  by  the  uterus 
being  so  tensely  distended.  In  bad  cases  one  always  finds,  in  addition, 
extreme  restlessness,  great  pain,  distension,  and  tenderness  of  the 
abdomen.  Sometimes  the  tenderness  and  distension  are  confined  more 
especially  to  one  part,  where  presumably  the  separated  placenta  is.  On 
palpating  the  uterus  it  is  always  found  very  hard  and  globular  ;  person- 
ally I  can  never  remember  having  found  it  boggy.  It  is,  as  a  rule,  im- 
possible to  make  out  the  fcetal  parts.  By  vaginal  examination  the 
membranes  can  be  felt  through  the  os  more  than  usually  tense. 

Prognosis  for  Mother  and  Child. 

In  most  of  the  cases  where  the  haemorrhage  is  slight  the  outlook 
is  not  serious.  Whenever  the  bleeding  is  at  all  pronounced,  however, 
and  especially  if  it  is  concealed,  the  dangers  to  mother  and  child  are 
very  great.  As  regards  the  mother  there  is  probably  no  complication, 
w7ith  the  exception  of  rupture  of  the  uterus,  in  which  her  life  is  placed 
in  greater  danger.  Statistics  are  unreliable,  for  if  the  slight  cases  are 
included  in  a  series,  then  the  mortality  will  appear  comparatively 
small.     In  the  grave  cases  there  is  a  mortality  of  40  to  GO  per  cent. 

Ae  regards  the  children,  unless  the  placental  separation  is  very 
slight  indeed,  they  always  perish. 

Treatment. 

Before  discussing  such  a  contentious  subject  as  the  treatment  of 
accidental  haemorrhage,  let  me  remark  that  this  complication  is  on 
quite  a  different  footing  as  regards  treatment  to  the  other  form  of 
haemorrhage  which  we  have  just  considered — namely,  placenta  praevia. 
Accidental  haemorrhage  almost  invariably  results  in  the  death  of  the 
child,  so  that  its  life,  except  where  the  haemorrhage  is  very  slight, 
need  not  be  considered.  The  treatment  is  entirely  directed,  therefore, 
to  saving  of  the  mother. 

As  the  clinical  features  and  severity  in  the  different  varieties  of 
accidental  haemorrhage  differ,  so  also  should  the  treatment.  Let  us 
first  of  all  consider  the  cases  where  the  ha-morrhage  is  apparent,  and 
where,  as  far  as  can  be  j  udged  from  the  clinical  features,  there  is  little 
concealed.  All,  I  think,  will  agree  that  in  the  slight  cases  of  this 
variety,  which  occur  during  labour  in  a  uterus  contracting  satisfac- 
torily, the  simple  procedure  of  rupturing  the  membranes  is  all  that  is 
required.  It  is  not  even  necessary  in  most  cases  to  perform  version, 
which  has  the  objection  of  complicating  the  delivery,  and  diminishing 


ACCIDENTAL  HEMORRHAGE— ABLATIO  PLACENTAE    601 

the  chances  of  obtaining  a  living  child,  for  in  this  variety  one  occasion- 
ally is  fortunate  enough  in  saving  the  child. 

When  the  haemorrhage  occurs  before  labour  has  started,  or  only 
just  at  its  commencement,  the  procedure  to  be  followed  is  quite 
different.  In  such  cases  there  are  three  distinct  methods  of  treat- 
ment :  (a)  Plugging  the  cervix  and  vagina  ;  (l>)  rupturing  the 
membranes ;  (c)  dilating  the  cervix  and  extracting  the  child 
(accouchement  force). 

Treatment  by  Plugging". — In  recent  years  in  this  country  the 
treatment  first  initiated  by  Leroux,  in  1776,  of  plugging  the  vagina 
has  been  revived,  and  has  been  very  strongly  recommended,  more 
especially  by  the  past  and  present  masters  of  the  Rotunda  Hospital. 
In  the  discussion  on  this  subject  at  the  British  Medical  Association  in 
1904,  Macan  and  other  Irish  obstetricians,  without  a  dissentient  voice, 
supported  this  treatment,  inaugurated  some  years  previously  in  the 
Rotunda  Hospital  by  Smyly.  Certainly  the  results  obtained  by  this 
method  in  the  practice  of  the  Rotunda  Hospital  have  been  of  a  highly 
satisfactory  nature,  as  can  be  judged  from  the  valuable  paper  on  the 
subject  by  Colclough,  in  which  he  showed  a  mortality  by  the  treatment 
of  slightly  under  5  per  cent.  At  the  same  meeting  Champneys 
supported  the  treatment  in  certain  cases.  Galabin  also  half-heartedly 
favoured  it,  but  pointed  out  that  in  the  old  statistics  of  Sinclair  and 
Johnston,  of  about  fifty  years  ago,  where  the  treatment  was  rupture  of 
the  membranes  and  acceleration  of  delivery,  the  mortality  was  only 
slightly  greater. 

In  Germany,  with  the  exception  of  Veit,1  Hofmeier,2  and  Nagel,3 
there  are  few  who  favour  the  treatment  by  plugging ;  the  same  also 
applies  to  France  and  America.  Amongst  those  who  condemn  the 
treatment  may  be  mentioned  Herman,4  who  writes  :  '  The  only  way 
in  which  it  does  good  is  by  irritating  the  cervix,  and  so  stimulating 
the  uterus  to  contract ;  it  is  a  clumsy  and  painful  way  of  doing  this.' 
Webster  :5  '  The  tampon  treatment  is  most  pernicious ;  it  has  no  scientific 
basis  whatever,  although  it  may  have  in  a  certain  class  of  cases  of 
placenta  previa.'  Holmes:6  'The  tampon  should  have  no  place  in 
the  treatment  of  ablatio  placenta?.' 

We  have  here,  then,  as  in  so  many  other  conditions,  two  absolutely 
opposite  opinions  by  equally  distinguished  obstetricians  on  the  treat- 
ment by  plugging.     It  is,  consequently,  not  a  little  difficult  to  decide 

1  '  Handbuch  ftir  Geburtshulfe,'  ii.,  p.  86. 

2  'Handbuch  der  Geburtshiilfe,'  Bd.  ii.,  Teil  ii.,  p.  1195. 

3  '  Operative  Geburtshiilfe,'  1902,  p.  299. 

4  '  Difficult  Labour,'  revised  edition,  1900,  p.  301. 

5  American  Journal  of  Obstetrics,  1901,  vol.  iv.,  p.  861.  t;  Op.  cit. 


602  OPERATIVE  MIDWIFERY 

who   is  in  the  right,  or,  what  is  more  important,  whether  or  not 
plugging  is  of  value  in  the  treatment  of  accidental  haemorrh 

There  are  two  conditions  in  which  it  is  agreed  by  every  one  thai 
plugging  is  unsuitable — viz..  when  the  membranes  are  ruptured,  and 
when  the  haemorrhage  is  concealed,  and  it  is  self-evident  why  thai 
should  he  so.  These  cases,  therefore,  may  he  dismissed  from  con- 
sideration at  present. 

Personally,  I  favour  the  treatment  by  plugging  in  certain  cases, 
and  for  the  simple  reason  that  it  is  the  only  method  of  imitating 
Nature's  cure.  On  several  occasions  I  have  watched  the  progress  of 
a  case  of  accidental  haemorrhage  which  has  been  left  entirely  to 
Nature,  and  I  have  found  that  by  the  formation  of  clots  the  further 
progress  of  the  haemorrhage  becomes  arrested.  But  during  such  a  time 
the  woman  loses  a  considerable  amount  of  blood,  and  sometimes 
Nature  cannot  control  the  condition,  and  so,  with  the  object  of 
favouring  clotting,  the  tampon  is  sound  treatment.  It  also,  of  course, 
has  the  effect  of  damming  back  the  blood,  stimulating  the  uterus  to 
contract,  and  dilating  the  os.  There  is  another  action  claimed  for  the 
plug  by  Tweedy — that  it  compresses  the  uterine  arteries  when  there  is 
a  tight  abdominal  bandage  pressing  down  the  uterus  from  above.  If 
the  contention  is  correct,  a  very  large  supply  of  blood  must  be  cut  off 
from  the  uterus.  In  other  words,  as  Tweedy  says,  arrestment  of 
bleeding  results  in  the  same  way  as  occurs  in  post-partum  haemor- 
rhage if  the  abdominal  aorta  is  compressed.  It  is  incorrect  to  say 
that  the  plugging  of  an  external  haemorrhage  simply  converts  it  into 
a  concealed  or  internal  one,  for  this  will  only  happen  if  the  uterine 
wall  is  unable  to  withstand  the  pressure  from  within. 

"We  have  had  in  the  Maternity  Hospital,  and  I  have  had  in  private 
practice,  some  highly  satisfactory  results  in  cases  of  apparent  accidental 
haemorrhage  by  plugging.  But  when  I  have  said  this  in  support  of  the 
plug,  used  as  I  shall  describe  it  immediately,  I  feel  that  I  have  said  all 
I  can  in  support  of  it;  for  there  are  certain  cases — those  in  which, 
although  the  haemorrhage  is  apparent,  it  is  also  to  a  large  extent 
concealed — in  which  the  treatment  by  plugging  must  be  used  with 
great  care.  The  patient  must  be  watched  constantly  as  regards  her 
general  condition,  more  especially  as  regards  her  pulse  and  the  effect 
that  the  distension  of  the  uterus  is  having  upon  her.  In  these  cases 
the  experience  and  judgment  of  the  operator  will  be  tested  to  the 
utmost,  and  he  must  be  prepared,  if  symptoms  of  the  more  serious 
form  of  concealed  hemorrhage  develop,  to  adopt  the  more  energetic 
treatment  we  shall  consider  later. 

In  plugging  for  accidental  haemorrhage  the  operation  should  be 
carried  out  as  follows  :  The  woman  is  placed  in  the  lithotomy  position. 


ACCIDENTAL  HEMORRHAGE— ABLATIO  PLACENTAE     G03 

1  The  external  genitals  are  then  thoroughly  cleansed  and  the  pubes 
!  shaved,  as  there  is  great  danger  of  sepsis.  The  vagina  also  should 
be  carefully  washed  out  with  a  weak  solution  of  lysol,  so  as  to  remove 
any  loose  blood-clot  which  maybe  present  in  its  upper  part.  The  material 
used  for  plugging  is  not  of  any  great  moment,  although,  without  doubt, 
plugs  of  absorbent  cotton-wool,  about  the  size  of  a  walnut,  fit  into  the 
■fornices  better  than  larger  tampons.  Sterilized  gauze  does  very  well 
if  tampons  are  not  available,  and,  of  course,  at  a  pinch,  any  linen  or 
cotton  boiled  will  do.  If  the  material  used  for  plugging  is  soaked 
in  an  antiseptic,  it  must  be  a  very  weak  solution,  as  otherwise  con- 
siderable damage  will  be  done  the  vaginal  mucous  membrane.  As 
such  a  weak  solution  can  have  no  germicidal  value,  it  is  quite 
unnecessary  to  employ  it. 

If  retractors  are  at  hand,  they  should  be  employed ;  although  it 
is  easy  to  use  one  hand  as  a  vaginal  retractor,  while  pushing  in  the 
plug  with  the  other,  the  vaginal  wall  is  much  more  likely  to  be 
damaged.  Having  packed  the  gauze  firmly  round  the  cervix  and 
filled  up  the  vagina  completely,  a  firm  abdominal  binder  is  applied 
over  the  uterus.  The  binder  is  fastened  from  above  downwards. 
Last  of  all,  a  perineal  pad  and  bandage  are  applied,  the  latter  being 
pinned  to  the  abdominal  binder. 

Rupture  of  the  Membranes. — It  is  perfectly  true,  as  has  been 
already  stated,  that  in  a  certain  number  of  cases  rupture  of  the 
membranes,  and  so  taking  off  the  strain  on  the  uterus,  and  allowing 
its  walls  to  retract  over  the  child,  is  sufficient.  As  Barnes1  says, 
'  Nature  will  do  the  rest.'  In  a  very  large  number  of  cases,  however, 
and  these  the  most  serious,  rupture  of  the  membranes  is  not  sufficient, 
and  even  the  strongest  supporters  of  this  treatment  admit  this  in  their 
writings,  for  they  all,  as  witness  Barnes  and  Herman,  refer  to  what 
should  be  done  should  hemorrhage  continue. 

Rupturing  the  membranes  is  usually  quite  sufficient  in  cases  where 
labour  has  been  in  progress  for  some  time  and  the  uterus  is  contracting 
well.  But  should  one  adopt  this  simple  procedure  where  the  cervix  is 
still  undilated  and  the  uterine  contractions  are  not  active,  one  is  very 
awkwardly  placed  indeed  if  the  hemorrhage  continues  ;  a  foot  cannot 
be  brought  down,  and  there  will  be  difficulty  even  in  introducing  the 
metreurynter.  Both  the  older  results,  such  as  those  of  Goodell  and 
Hicks,  and  the  more  recent  results  of  Smyly — an  opponent  to  the 
treatment  by  rupture  of  the  membranes — are  far  from  satisfactory, 
and  were  it  not  for  the  dernier  ressort  of  the  metreurynter  no  present- 
day  obstetrician  would  favour  the  treatment.  Hofmeier,'2  writing  on 
this   subject,    says :    '  Rupture    of    the   membranes    should   only    be 

1  '  Obstetric  Operations,'  p.  426.  2  Op.  cit. 


604  OPERATIVE   MII>\YJIT.I;Y 

employed  when  the  bleeding  is  not  very  strong,  when  the  pains  are 
good,  and  when    labour   has  advanced  so  far  that  rapid  delivery  is 

-ihle  should  it  hecome  necessary.1  Practically  all  other  modern 
writers  express  themselves  in  similar  terms. 

Dilatation  of  the  Cervix— Extraction  of  the  Child— Accouche- 
ment Force. — At  the  present  moment  on  the  Continent  of  Kurope 
and  America  the  treatment  by  the  metreurynter  is  probably  the  one 
most  favoured;  in  Jlolmes'  paper  this  is  the  treatment  recom- 
mended for  severe  cases  not  in  labour.  Others  in  America,  such  as 
Jewett,1  Hirst,2  and  Williams,3  all  favour  this  method.  In  this  country 
Herman,  Eden,  and  most  recent  writers,  with  the  exception  of  the 
liotunda  school,  favour  the  treatment,  and  trust  to  it  rather  than  the 
plug. 

Without  doubt  this  treatment  has  its  place,  and  the  cases  in  which 
personally  I  believe  it  is  suitable  are  where  there  is  a  moderately 
severe  internal  haemorrhage,  in  which  one  is  not  quite  prepared  to 
adopt  the  very  radical  treatment  that  is  now  recommended  for  the 
very  grave  forms  of  concealed  accidental  haemorrhage.  To  my  mind, 
therefore,  it  is  the  most  suitable  treatment  in  cases  unsuitable  for 
plugging,  but  not  severe  enough  for  hysterectomy. 

As  regards  treatment  by  more  active  dilatation,  such  as  that 
carried  out  by  means  of  Bossrs  dilators,  obstetricians  one  and  all  are 
opposed  to  such  a  procedure.  Our  results  in  the  Maternity  Hospital 
by  this  treatment  have  been  most  unsatisfactory.  The  shock  produced 
to  the  patient — and  it  must  be  remembered  she  is  already  very  much 
shocked — is  very  great,  the  danger  of  laceration  of  the  cervix  is  not 
inconsiderable,  and  the  probability  of  post-partum  haemorrhage  by 
no  means  remote. 

Abdominal  and  Vaginal  Caesarean  Section. — I  have  dealt  suffici- 
ently exhaustively,  and  above  all,  clearly,  I  hope,  with  the  treatment  of 
accidental  haemorrhage  as  one  meets  with  it  generally.  I  have  pointed 
out  how  in  slight  bleeding  during  labour  simple  rupture  of  the 
membranes  is  sufficient ;  how  in  the  apparent  hemorrhage  during 
pregnancy  or  early  in  labour,  the  best  results  are  obtained  by  plugging ; 
how  in  the  mixed,  especially  those  in  which  a  large  quantity  of  blood 
is  concealed,  the  metreurynter  should  be  employed,  and  after  its 
expulsion  the  child  extracted  by  forceps  or  version. 

There  now  only  remain  to  be  considered  those  severe  cases  of 
concealed  accidental  haemorrhage,  which  are  fortunately  not  common. 

It   is   a   very    striking    fact    that,    as    regards    this,    the    most 

1  '  Tracticc  of  Obstetrics,'  2nd  edition,  1902,  p.  528. 
-  '  Text-] look  of  Obstetrics,'  1899,  p.  536. 
3  'Obstetrics,'  2nd  edition,  1907,  p.  808. 


ACCIDENTAL  HEMORRHAGE— ABLATIO  PLACENTA    605 

serious  group  of  cases,  there  is  gradually  coming  to  be  a  greater 
uniformity  of  opinion.  Year  by  year  one  finds  the  active  treat- 
ment, which  I  shall  refer  to,  more  and  more  advocated.  At 
the  British  Medical  Association  at  Oxford,  in  190-1,  when  this 
subject  of  accidental  hemorrhage  was  discussed,  all  the  speakers 
without  exception,  held  more  or  less  the  same  opinion  regarding  the 
treatment  of  these  most  serious  and  fatal  cases  now  under  con- 
sideration. 

The  results  obtained  from  all  the  ordinary  forms  of  treatment  in 
cases  of  severe  accidental  hemorrhage  have  been  so  unsatisfactory 
that  modern  obstetricians  have  been  forced  to  adopt  most  radical 
measures  in  the  hope  of  lessening  the  maternal  mortality.  The 
treatment  consists  in  emptying  the  uterus,  and  in  most  cases  removing 
that  organ.  This  may  be  done  either  by  the  abdomen  or  by  the 
vagina.  The  reason  why  the  uterus  is  removed  is  that  it  has  been 
found  that,  after  emptying  it,  hemorrhage  often  continues,  and  that 
there  is  great  difficulty  in  controlling  this  post-partum  haemorrhage 
even  by  plugging.  I  entirely  agree  with  this  attitude  towards  this 
condition.  In  the  grave  cases  of  concealed  accidental  haemorrhage 
the  uterus  is  in  a  state  of  atony,  and  cannot  possibly  be  aroused  from 
that  state  by  massage,  douche,  etc.- 

One  finds  advocates  both  of  the  abdominal  and  vaginal  route,  and 
there  is  much  to  be  said  for  each.  The  advantages  of  the  abdominal 
route  are  that  the  operation  is  easier,  that  there  is  less  risk  of  injuring 
the  bladder,  and  that  the  subsequent  removal  of  the  uterus  is  not 
difficult.  The  advantages  of  the  vaginal  route,  on  the  other  hand,  are 
that  the  risks  of  infection  are  less. 

Quite  a  number  of  successful  cases  have  been  recorded  by  both 
methods.  In  the  two  cases  in  which  I  have  adopted  hysterectomy  I 
chose  the  abdominal  route.  In  neither  of  the  cases  did  the  treatment 
prove  successful.  One  died  almost  immediately  after  the  operation, 
while  the  other  succumbed  to  sepsis  on  the  fifth  day.  In  the  latter 
case  it  was  specially  disappointing  that  this  happened,  as  her  progress 
after  hysterectomy  for  the  first  two  days  was  extremely  satisfactory. 
Both  these  patients  were  admitted  into  the  Maternity  Hospital  pro- 
foundly collapsed,  and  I  am  perfectly  certain  no  other  treatment 
would  have  been  more  successful.  Targett1  has  reported  a  success- 
ful case,  and  scattered  through  the  literature  of  the  various 
countries  are  to  be  found  not  a  few  successes.  The  form  of  abdominal 
hysterectomy  to  be  performed  in  these  cases  is  supravaginal  amputa- 
tion of  the  uterus,  with  a  retroperitoneal  treatment  of  the  stump,  an 
operation  described  on  p.  418.     The   vaginal  Cesarean    section,  so 

1  Trans.  Lond.  Obst.  Soc,  vol.  xlvii.,  p.  147. 


006  OPERATIVE  MIDWIFKKY 

strongly  recommended  by  Puhrssen,  Bumm,  and  others  is  fully 
detailed  on  p.  170.  In  (Icrniany  several  successful  cases  have  been 
recorded  by  this  method,  and  it  may  be  that  it  will  be  more  extensively 
employed  in  the  future.  The  objection  to  the  vaginal  Caesarean 
section,  with  the  subsequent  extraction  of  the  uterus  by  the  vagina, 
that  there  would  be  a  difficulty  in  removing  the  large  uterus,  has  not 
been  found  to  be  the  case.  The  objection  is  purely  theoretical. 
Several  operators,  including  Wilson  of  Birmingham  and  myself,  have 
described  cases  where  the  full-time  uterus  has  been  removed  without 
difficulty  through  the  vaginal  canal.  The  uterus  becomes  so  relaxed 
and  stretched  out  that  by  steady  traction  it  is  readily  dragged  down. 

As  I  have  already  stated,  'If  vaginal  Cesarean  section  is  to  have 
a  permanent  place  amongst  the  recognized  obstetric  operations  of  the 
later  months  of  pregnancy,  there  is  no  condition  more  suited  for  this 
method  of  treatment  than  severe  concealed  accidental  hemorrhage.' 
And  I  say  this  for  two  reasons — (1)  The  child,  as  we  have  seen,  is 
negligible  ;  it  is  always  dead,  and  so  the  after-coming  head  may  be 
perforated  always  and  easily  extracted.  (2)  The  uterus  is  negligible  ; 
it  should  be  removed,  and,  consequently,  it  does  not  matter  how  it 
is  incised  or  torn.  When  speaking  of  vaginal  Ca?sarean  section  in 
Chapter  XXVIII.,  where  the  operation  is  described,  I  pointed  out  that 
my  objection  to  the  operation  in  the  later  months  of  pregnancy  was 
the  danger  of  injuring  the  lower  uterine  segment.  Naturally  that 
objection  cannot  be  raised  if  the  uterus  is  removed. 

The  accoucheur  who  is  accustomed  to  vaginal  operations  will  have 
no  difficulty  in  removing  the  full-time  uterus  by  the  vagina.  The 
quickest  way  of  dealing  with  the  vessels  is  by  securing  the  broad 
ligaments  with  clamps,  and  in  cases  where  this  route  is  chosen  I 
would  advise  this  method  of  treatment,  for  the  operation  can  be  per- 
formed in  a  few  minutes.  It  is  all-important  that  the  clamps  should 
have  the  ridges  on  the  blades  running  longitudinally,  otherwise  they 
are  apt  to  slip.  They  should  be  removed  at  the  end  of  forty-eight 
hours. 


CHAPTER  XXXIV 

POST-PARTUM  HEMORRHAGE 

Post-partum  haemorrhage  is  commonly  divided  into  primary  and 
secondary ;  '  primary  '  is  the  haemorrhage  that  occurs  during  the 
first  twenty-four  hours  after  delivery,  and  '  secondary,'  or  puerperal 
hemorrhage,  that  which  occurs  later. 

Primary  Post-Partum  Haemorrhage 

Post-partum  haemorrhage  of  a  severe  type  is  a  complication  which 
one  now  sees  comparatively  seldom  in  hospital  and  private  practice. 
The  explanation  of  this  satisfactory  state  of  affairs  is  that  the  second 
and  third  stages  of  labour  are  managed  much  more  carefully  than  in 
former  years.  It  is  no  exaggeration  to  state  that  the  all-important 
preventive  against  post-partum  haemorrhage  is  a  proper  management 
of  these  stages  of  labour. 

It  does  happen  occasionally,  however,  in  spite  of  the  utmost  care, 
that  severe  haemorrhage  follows  the  expulsion  of  the  child,  so  that  in 
a  very  short  time  the  woman  may  be  so  exsanguinated  that  death 
results ;  but  that  is  not  the  most  common  type  of  post-partum 
haemorrhage.  More  generally  the  haemorrhage  is  less  severe,  and 
there  is  some  slight  attempt  at  uterine  retraction  and  contraction. 

Post-partum  bleeding  may  occur  from  the  placental  site,  or  from 
tears  and  lacerations  in  cervix,  vagina,  and  vulva.  Haemorrhage  from 
the  placental  site  is  the  most  important,  but  it  is  well  not  to  forget 
that  occasionally  severe  haemorrhage  occurs  from  tears  in  the  situations 
I  have  mentioned.  I  quite  agree  with  Herman1  that  lacerations  of 
the  cervix  are  very  rarely  associated  with  severe  haemorrhage. 
Herman  writes :  '  One  cannot  say  it  is  impossible  for  a  torn  cervix 
to  cause  dangerous  post-partum  haemorrhage,  but  I  doubt  if  it  ever 
does.'  Personally,  I  have  only  seen  it  in  two  eases,  where  the  lacera- 
tion extended  into  the  broad  ligament.  These  cases  are  considered  in 
Chapter  XXXV.     Tears  of  the  vaginal  wall  and  lacerations  of  the 

1  Practitioner,  April,  1907. 
607 


608  <>!T.l;.\TI\  E  MIDWIFERY 

perineum  may  also  be  associated  with  a  considerable  amount  of 
bleeding,  but  I  have  Been  the  worst  bleeding  of  all  occur  from  tears  of 
the  vestibule  in  the  neighbourhood  of  the  clitoris. 

Haemorrhage  from  lacerations  of  the  parturient  canal  is  to  be 
distinguished  from  hamorrhage  from  the  placental  site  by  the  fact 
that  with  the  former  the  uterus  is  firmly  retracted,  although  bleeding 
still  goes  on. 

The  repairing  of  lacerations  of  the  cervix  and  the  perineum  is 
described  in  Chapter  WW.  Tears  of  the  vestibule  are  only  to  In- 
dealt  with  by  deeply  understitching  the  part.  A  needle  is  passed  down 
to  the  bone  wide  of  the  bleeding-point,  and  a  ligature  carried  round 
the  bleeding  centre  (purse-string  suture). 

"We  must  now  turn  to  the  ordinary  post-partum  haemorrhage — that 
is,  the  haemorrhage  which  occurs  from  the  placental  site.  The  im- 
mediate causes  of  post-partum  hemorrhage  of  this  variety  are  primary 
and  secondary  uterine  inertia  or  exhaustion.  The  former  is  favoured 
by  overdistension  of  the  uterus,  from  hydramnios  or  plural  pregnancy, 
tumours  of  the  uterine  wall,  etc.,  but  most  of  all  by  a  diseased 
condition  of  the  uterus,  seen  so  commonly  in  multiparas  the  subjects 
of  chronic  metritis.  The  latter,  secondary  inertia  or  exhaustion  of 
the  uterus,  also  results  from  the  conditions  already  mentioned,  but  it 
is  seen  in  its  most  typical  form  in  cases  of  prolonged  parturition  where 
there  is  a  disproportion  between  the  parturient  canal  and  ftetus  or 
some  malposition  of  the  fcetus. 

It  will  be  observed  that  I  have  not  mentioned  precipitate  labour, 
for  I  have  seldom  seen  grave  post-partum  haemorrhage  in  that  condition. 
In  cases  of  Cesarean  section,  for  example,  where  the  child  is  rapidly 
extracted,  it  seldom  occurs,  and  when  it  has  occurred  the  uterus  was 
invariably  exhausted.  Neither  have  I  mentioned  pathological  con- 
ditions of  the  blood,  as  found  in  haemophilia,  anaemia,  and  general 
debility,  for  I  believe  that  these  conditions  are  of  comparatively  little 
account.  But  there  is  one  thing  which  I  feel  convinced  favours  post- 
partum hemorrhage,  and  that  is  the  long-continued  administration  of 
chloroform.  In  private  practice  amongst  the  wealthier  classes  a  light 
anesthesia  is  often  kept  up  for  many  hours.  In  such  cases  I  have 
often  found  the  retractility  of  the  uterus  greatly  impaired. 

The  diagnosis  of  post-partum  hemorrhage  is  simple  when  the 
uterus  remains  absolutely  flaccid  and  blood  is  gushing  from  it.  The 
condition  may  not,  however,  be  fully  appreciated  when  there  is  a 
slow  oozing  of  blood,  and  the  uterus  contracts  slightly  from  time  to 
time.  In  these  cases  the  blood  often  becomes  pent  up  in  the  uterus, 
and  only  a  small  quantity  escapes,  so  that  the  uterus  slowly  distends, 
and  the  condition  is  only  recognized  when  the  accoucheur,  on  pressing 


POST-PARTUM  H/EMORRHAGE  609 

it,  forces  out  a  large  quantity  of  blood-clot,  and  finds  the  patient  un- 
expectedly becoming  collapsed.  The  latter  type  is  the  more  common, 
but  the  least  serious.  Cases  belonging  to  it  can  always  be  saved,  for 
there  is  a  certain  degree  of  activity  left  in  the  muscle-fibres  of  the 
uterus.  Cases  of  the  former  type  are  naturally  much  more  grave,  and 
must  be  dealt  with  promptly  and  energetically  if  the  patients  are  to 
be  rescued. 

Treatment. 

Prophylactic. — Before  discussing  the  treatment  of  post-partum 
haemorrhage,  I  must  say  a  word  or  two  about  the  prevention  of  this 
■condition. 

Although  the  patient  who  has  had  experience  of  post-partum 
haemorrhage  need  not  at  a  subsequent  labour  be  again  afflicted  with 
this  complication,  there  is  no  doubt  that  it  is  to  her  advantage  to  have 
any  pathological  condition  of  the  uterus  corrected,  and  to  have  her 
general  health  kept  at  as  high  a  level  as  possible  during  her  preg- 
nancy, in  case  of  the  complication  recurring.  The  particular  patho- 
logical condition  of  the  uterus  that  should  be  suspected,  and  if 
possible  remedied,  is  a  chronic  metritis.  Unfortunately,  however,  it 
does  not  yield  very  readily  to  treatment.  The  administration  of  small 
•doses  of  ergot  and  strychnine  during  the  later  weeks  of  pregnancy  is 
generally  recommended  in  such  cases,  with  the  object  of  improving 
the  muscular  contractility  and  innervation  of  the  uterus.  I  am  in 
the  habit  of  giving  these  drugs,  but  I  cannot  say  if  they  have  done 
good.  One  thing  is  certain — they  cannot  do  any  harm.  In  recent 
years  the  exhibition  of  chloride  of  calcium  has  been  recommended 
because  of  its  property  of  favouring  coagulation  of  the  blood.  As  I 
have  already  indicated,  however,  post-partum  haemorrhage  is  only  to 
be  prevented  by  securing  uterine  retractility  and  contractility. 

The  greatest  factor  in  preventing  post-partum  haemorrhage  is  the 
proper  management  of  the  second  and  third  stages  of  labour.  It  is 
quite  impossible  to  discuss  here  the  whole  management  of  the  second 
stage  of  labour,  so  I  will  only  refer  to  the  one  all-important  point — 
namely,  the  danger  of  extracting  the  child  while  the  uterus  is  in  a  condi- 
tion of  secondary  inertia.  The  uterus  in  that  condition  is  tired  and 
worn  out ;  it  requires  rest :  opium  is  the  drug  to  give.  When  the 
uterine  contractions  recur  and  do  not  complete  the  delivery,  then 
extraction  may  be  performed  with  absolute  safety.  The  management 
of  the  third  stage  has  been  considered  in  Chapter  XXX.,  so  that  I  need 
not  refer  to  the  subject  here. 

Active. — Post-partum  haemorrhage  can  only  be  controlled  by 
■establishing  retraction  and  contraction  of   the   uterus.     It  is  never 

39 


010  OPERATIVE  MIDWIFERY 

encountered  when  the  uterus  is  firmly  retracted,  nor  will  it  ever  fail 
to  occur  when  the  uterus  is  flabby  and  in  a  condition  of  atony. 

There  has  been  a  great  deal  of  discussion  about  the  meaning 
of  these  two  terms  '  retraction '  and  '  contraction.'  For  a  simple 
explanation  of  them  I  cannot  do  better  than  refer  my  readers  to 
Herman's  recent  remarks  on  the  subject.1  Herman  says  :  '  I  will  not 
discuss  definitions,  but  I  will  describe.  Anyone  who  puts  his  hand  on 
the  abdomen  of  a  woman  who  has  just  been  naturally  delivered  will 
feel  the  uterus.  It  is  firm ;  its  shape  is  definite  ;  its  inner  wall  is 
applied  to  the  placenta  ;  its  muscular  fibres  are  grasping  and  con- 
stricting the  vessels,  and  in  this  condition  it  remains.  This  is 
retraction.  Every  few  minutes  the  uterus  becomes  smaller  and 
harder ;  it  grasps  the  vessels  more  tightly,  and  it  squeezes  the 
placenta ;  and  if  the  placenta  is  loose,  it  squeezes  it  out.  This  is 
contraction.  The  patient  is  not  safe  in  the  third  stage  of  labour  until 
this  condition  of  retraction  with  intermittent  contraction  has  come 
to  stay.' 

The  first  thing  to  do  in  order  to  try  and  secure  this  condition  of 
retractility  and  contractility  is  to  massage  the  uterus.  The  uterus 
is  seized  between  the  fingers  and  thumb  and  rubbed  firmly.  If  the 
placenta  has  not  been  delivered,  it  should  be  expressed.  In  the 
slighter  degrees  of  post-partum  haemorrhage  the  expression  of  the 
placenta  and  of  blood-clot  ends  one's  anxiety  about  the  condition  ; 
bnt  in  the  graver  cases,  where  the  uterus  does  not  respond  to  massage, 
the  hand  must  be  immediately  introduced  into  the  uterus,  and  the 
placenta,  if  it  is  still  there,  and  all  blood-clot  removed.  Before 
doing  this  it  is  well  to  pull  on  a  sterilized  glove,  for  one  seldom 
has  time  to  resterilize  the  hand,  which  has  become  contaminated  to 
a  slight  extent.  I  have  discussed  the  advantages  and  disadvan- 
tages of  gloves  elsewhere.  If  the  accoucheur  has  not  gloves,  he 
should  cleanse  his  hands  once  again,  provided  there  is  time  for  doing 
so.  If  there  is  not  time,  then  he  must  run  the  risk  of  introducing 
his  hand  soiled  as  it  is.  Provided  he  has  previously  thoroughly 
disinfected  his  hands  before  delivering  the  child,  the  risk  is  not 
great. 

Very  generally  the  removal  of  all  blood-clot  and  the  manipulations 
of  the  hand  in  the  uterus  bring  about  uterine  contractions.  Whether 
or  not  that  occurs,  an  intra-uterine  douche  of  sterilized  water  at  a 
temperature  of  about  118°  (water  at  this  temperature  is  uncomfort- 
ably hot,  but  not  more  than  that,  to  the  skin  of  the  forearm)  should 
be  given.  In  addition  to  the  douche  ergotin  should  be  injected  into 
the  buttock :  10  to  20  minims  of  the  aseptic  ergotin  supplied  in  little 

1  Op.  cit.,  p.  447. 


POST-PARTUM  HEMORRHAGE 


Gil 


glass  capsules  is  the  best  preparation ;  liquid  extract  given  by  the 
mouth  (2  drachms)  is  much  slower  in  its  action.  If  these  means  are 
ineffective  in  producing  satisfactory  retraction  of  the  uterus,  the  hand 
should  be  again  introduced,  the  uterus  stimulated,  and  the  surface 
again  gone  over  with  the  fingers,  in  case  there  may  still  be  some 
membrane  or  placenta  left  behind,  and  another  douche  given. 

I  have  only  twice  seen  this  treatment  fail  to  arrest  the  bleeding, 
and  in  both  of  these  cases  I  packed  the  uterus  with  gauze,  which  I 
believe  is  the  best  course  to  follow.  One  should  always  carry  a 
quantity  of  broad  iodoform  gauze,  sufficient  to  pack  the  uterus  and 
vagina.     Supplied  in  the  tins  of  Diihrssen,  it  can  be  carried  about 


Fig.  276. — The  left-hand  figure  shows  a  Uterus  carefully  plugged  with  Gauze;  the  right- 
hand  one  a  Uterus  in  which  only  the  Lower  Uterine  Segment  is  packed. 

A,  Retraction  ring  ;  B,  cavity  of  uterus  unpacked.     (Bumm.) 


very  conveniently.  In  order  to  arrest  the  bleeding  the  packing  must 
be  thorough.  It  is  best  performed  by  pulling  down  and  steadying 
the  cervix  with  vulsellum  forceps,  and  stuffing  in  the  gauze  with 
the  hand.  Gauze  forceps  are  not  nearly  so  good.  After  the  uterus  is 
thoroughly  packed,  the  vagina  should  be  plugged,  a  pad  should 
be  placed  round  the  fundus,  and  a  firm  abdominal  binder  applied. 
B)i  this  means  tlie  bleeding  can  be  absolutely  controlled. 

The  illustration  (Fig.  276)  shows  a  mistake  often  made  of  packing 
Dnly  the  lower  uterine  segment.  Such  plugging  is  naturally  quite 
ineffectual  in  arresting  haemorrhage. 


012 


OPERATIVE  MIDWIFERY 


I  am  quite  aware  that  many  operators,  especially  in  this  country, 
are  opposed  to  plugging  the  uterus.  Herman,  for  instance,  is  opposed, 
to  it,  and  Eden1  gives  it  a  very  half-hearted  support.  Tweedy,*2  how- 
ever, approves  of  it,  and  many  American  and  German  accoucheurs 
recommend  it. 

The  alternative  to  plugging  is  bimanual  compression  of  the  uterus  ; 


Fig.  277. — Bimanual  Compression  of  Uterus  for  the  Purpose  of  arresting  Postpartum 
Haemorrhage.    (Bumm.) 

that  is  to  say,  the  whole  fist  is  introduced  into  the  uterine  cavity,  and 
the  uterine  wall  is  squeezed  between  the  fist  and  the  external  hand- 
It  is  claimed  that  this  is  a  better  method  of  compressing  the  uterus 
than  the  one  illustrated,  where  the  hand  in  the  vagina  grasps  the 
cervix,  and  the  external  hand  grasps  the  fundus  and  doubles  the  body 
on  the  cervix  (Fig  277).     I  very  much  question  if  this  manual  com- 

1  '  Manual  of  Midwifery,1  1906. 

2  '  Potunda  Practical  Midwifery,'  1908,  p.  291. 


POST-PARTUM  HAEMORRHAGE  613 

pression  is  better  than  plugging,  and  in  any  case  one  cannot  keep 
it  up  for  any  length  of  time.  In  desperate  cases,  as  a  temporary 
measure,  manual  compression  of  the  abdominal  aorta  by  the  fist  may 
be  employed. 

In  carrying  out  this  treatment  the  accoucheur  or  his  assistant 
should  stand  above  the  patient,  place  his  fist  over  the  aorta,  and  lean 
the  whole  weight  of  his  body  on  his  straightened-out  arm.  By  that 
means  he  can  keep  up  pressure  for  an  indefinite  period,  but  if  he 
tries  to  do  the  same  by  pressure  with  the  arm  bent,  he  will  soon 
become  exhausted. 

More  radical  suggestions  have  been  made  for  dealing  with 
desperate  cases  of  post-partum  haemorrhage.  It  has  been  recom- 
mended that  the  uterine  vessels  should  be  clamped,  and  that  the 
uterus  should  be  removed.  It  has  even  been  suggested  that  the 
uterus  should  be  artificially  inverted.  I  will  not  discuss  such  methods, 
however,  for  I  do  not  believe  that  they  are  ever  necessary. 

In  the  text-books  of  twenty  or  thirty  years  ago  the  swabbing  of 
the  uterine  cavity  with  a  styptic  solution  was  recommended,  the  idea 
being  that  the  bleeding  could  be  controlled  by  producing  thrombosis 
of  the  vessels.  For  this  purpose  such  substances  as  perchloride  of 
iron  and  vinegar  were  employed.  I  could  hardly  have  believed  that 
such  measures  were  still  in  use,  yet  a  case  came  under  my  notice 
some  few  years  ago  where  a  practitioner  packed  the  vagina  and 
uterus  with  gauze  soaked  in  vinegar  ;  the  consequences  were  very 
serious,  for  the  entire  mucous  membrane  sloughed.  In  recent  years 
swabbing  with  a  weak  solution  of  adrenalin,  1  in  1,000  to  1  in  2,000, 
or  soaking  a  portion  of  the  gauze  in  such  a  solution,  has  been  recom- 
mended. I  feel  sure  it  is  unsound  treatment  for  this  kind  of  haenior- 
rhage,  and  if  employed  is  bound  to  result  in  destruction  of  tissue, 
which  naturally  favours  the  invasion  of  saprophytic  organisms. 

Treatment  of  Collapse  from  Haemorrhage. 

So  far  in  discussing  the  different  varieties  of  haemorrhage  I  have 
only  incidentally  referred  to  the  manner  in  which  the  collapse  should 
be  overcome.  Certainly  it  is  all-important  to  arrest  the  bleeding,  but 
it  has  also  been  abundantly  proved  in  recent  3Tears  that,  unless  fluid 
is  added  to  the  circulation  to  take  the  place  of  the  blood  lost,  the 
patient  may  die  even  although  the  bleeding  has  been  stopped. 

After  arresting  the  haemorrhage,  of  first  importance  is  maintaining 
the  vital  organs  of  the  body,  such  as  the  brain  and  abdominal 
viscera  well  supplied  with  blood.  This  is  done  by  raising  the  foot 
of  the  patient's  bed,  and,  if  thought  desirable,  although  it  is  of  less 


614  OPERATIVE  MIDWIFERY 

importance,  applying  bandages  round  the  limbs  (auto-transfusion). 
Secondly,  an  amount  of  fluid  should  be  added  to  the  circulation  to 
take  the  place  of  the  blood  lost.  This  may  be  done  in  a  variety  of 
ways.  Fluid  ma}7  be  introduced  into  the  rectum,  the  subcutaneous 
connective  tissue,  or  directly  into  a  vein. 

Rectal  injections  of  warm  saline  solution  (temperature  102°)  is  the 
simplest  method  of  introducing  the  fluid,  but,  owing  to  the  enfeebled 
circulation,  absorption  is  often  too  slow.  Should,  however,  it  be  the 
only  possible  and  convenient  method  of  giving  the  fluid,  it  is  hest 
given  with  a  syphon-douche.  In  recent  years  it  has  been  found  that 
great  benefit  follows  a  continuous  saline  rectal  infusion.  About  a 
pint  per  two  hours  is  allowed  to  flow  slowly  into  the  rectum.  This 
continuous  infusion  is  most  valuable  in  cases  of  profound  shock 
following  severe  abdominal  operations.  In  the  case  of  shock  following 
haemorrhage  the  fluid  must  be  introduced  into  the  circulation  more 
rapidly,  and  so  intracellular  or  intravenous  infusion  is  better. 

Intracellular  transfusion  is  more  rapid  in  its  action.  The  fluid 
may  be  injected  into  the  loose  connective  tissue  over  the  abdominal 
wall  or  back,  but  it  is  even  better  to  inject  it  into  the  loose  tissue 
underneath  the  breasts.  All  that  is  required  for  this  operation  is  a 
filler,  a  piece  of  rubber  tubing,  and  a  large  trocar  and  cannula.  This 
simple  apparatus  should  always  be  carried  by  the  obstetrician.  The 
solution  employed  consists  of  boiled  water  at  a  temperature  of  101°, 
to  which  is  added  common  salt  (sterilized  common  salt  or,  better, 
salt  tabloids)  in  the  proportion  of  a  drachm  to  the  pint.  One  or  two 
pints  of  fluid  are  injected.  If  the  breast  is  chosen,  a  very  convenient 
method  is  to  introduce  simultaneously  by  means  of  a  double  tube 
a  pint  into  each  breast.  The  tissue  underneath  the  breasts  cannot 
usually  contain  comfortably  more  than  about  a  pint.  During  the 
operation  the  tissues  should  be  gently  massaged  to  hasten  the  absorp- 
tion of  the  fluid.  After  the  trocar  is  withdrawn,  a  collodion  dressing 
is  applied,  and  two  pieces  of  adherent  plaster  placed  over  it. 

The  most  rapid  method  of  introducing  fluid  into  the  circulation  is 
through  a  vein.  The  median  basilic  is  the  one  generally  chosen. 
This  simple  operation  is  carried  out  without  an  anaesthetic,  seeing 
that  the  patient  is  so  extremely  collapsed.  The  steps  are  as  follows  : 
A  bandage  is  applied  round  the  lower  part  of  the  upper  arm  : 
this  makes  the  veins  of  the  forearm  stand  out.  An  incision  is 
made  over  the  vein  for  about  1  inch.  The  vein  is  separated  from 
the  tissues,  and  a  loop  of  fine  silk  applied  underneath  it.  An 
opening  is  made  into  the  vein  and  a  blunt  needle  introduced.  Care 
must  be  taken  that  no  air  is  allowed  to  enter.  The  ligature  is  tied 
over  the  needle.     One  or  two  pints  of  fluid  is  allowed  to  enter  slowly 


POST-PARTUM  HEMORRHAGE  615 

from  a  filler  held  not  more  than  about  1  foot  above  the  patient's 
arm.  The  needle  is  removed  and  the  vein  tied  in  two  places  and 
divided.  Lastly,  the  skin  wound  is  sutured  and  a  collodion  dressing 
applied. 

In  addition  to  the  means  described,  judicious  cardiac  stimulation 
is  of  value.  Brandy  or  whisky  (2  or  3  ounces)  should  be  given  by 
the  bowel,  and  strychnine  or  digitalin  should  be  injected  hypodermi- 
cally.  Care  must  be  taken  not  to  overstimulate  the  heart  at  this  stage. 
The  recovery  of  the  patient  is  often  surprisingly  rapid,  but  in  some 
cases  it  is  very  protracted.  It  should  not  be  unduly  hastened,  for  there 
are  late  dangers,  such  as  crural  and  pulmonary  thrombosis.  Last  of 
all,  there  is  the  danger  of  a  pernicious  anaemia  being  established. 

Secondary  Post-Partum  Haemorrhage. 

By  secondary  post-partum  haemorrhage  we  understand  haemorrhage 
which  occurs  any  time  in  the  puerperium  after  the  first  ten  hours. 
The  most  common  cause  of  this  complication  is  the  retention  in  the 
uterus  of  blood-clot,  pieces  of  membrane,  but  especially  pieces  of 
placenta.  Sometimes  it  is  purely  the  result  of  subinvolution,  but  in 
such  cases  the  amount  of  haemorrhage  is  usually  slight.  In  two 
cases  I  have  seen  a  very  profuse  haemorrhage  occurring  in  the  third 
and  fourth  weeks  of  the  puerperium,  when  the  patients  were  going 
about,  and  where  apparently  the  only  cause  was  a  backward  displace- 
ment of  the  uterus.  Submucous  myoma  calls  also  for  mention  as  a 
cause  of  post-partum  haemorrhage,  and  lastly,  chorion  epithelioma 
must  not  be  forgotten.  With  this  latter  tumour  the  bleeding  usually 
does  not  come  on  until  three  or  four  weeks  after  parturition. 

The  treatment  of  secondary  post-partum  haemorrhage  is  simple- 
If  the  haemorrhage  is  only  slight,  ergot  (liquid  extract,  a  teaspoonful 
morning  and  evening)  should  be  given  for  a  week,  the  patient  kept  at 
rest  in  bed,  and  hot  intra-uterine  douches  given.  If  this  does  not 
control  the  bleeding,  the  uterus  should  be  explored.  If  at  all  possible, 
this  exploration  should  be  done  by  the  finger,  and  it  is  often  possible, 
as  the  cervix  is  still  dilatable.  Any  displacement  of  the  uterus  should 
be  corrected,  while  a  submucous  myoma  should  be  removed.  In  the 
cases  of  chorion  epithelioma  the  uterus  should  be  removed  entire. 


CHAPTER  XXXV 

ACCIDENTS  TO  MOTHERS— LACERATIONS  OF  UTERUS,  VAGINA, 
PERINEUM,  SYMPHYSIS  PUBIS 

Rupture  of  the  Uterus. 

To  anyone  acquainted,  however  slightly,  with  obstetrics  the  mention 
of  rupture  of  the  uterus  at  once  suggests  a  labour  badly  managed. 
Such  a  view  is  in  the  main  correct,  for  without  doubt,  in  the  majority 
of  instances,  the  accident  must  be  considered  a  disgrace  to  the 
obstetric  art,  and  to  the  individual  who  has  had  charge  of  the 
parturient.  There  are,  however,  exceptional  cases  in  which  the 
accident  is  quite  unavoidable,  even  cases  when  it  occurs  during 
pregnancy. 

I  purpose  considering  rupture  at  three  distinct  periods  :  (a)  During 
pregnancy  ;  (b)  early  in  labour  ;  (c)  after  labour  has  been  protracted. 

Rupture  of  the  Uterus  during-  Pregnancy. 

Of  cases  belonging  to  this  group  the  most  numerous  are  those  in 
which  the  uterus  has  been  previously  injured.  Naturally,  the  injury 
which  first  occurs  to  one's  mind  is  a  previous  Cesarean  section  wound. 
There  are  quite  a  number  of  cases  in  which  such  a  wound  has  given 
way.  I  have  myself  described  one1  in  which  the  cicatrix  of  a  fundal 
incision  gave  way ;  similar  cases  have  been  reported  by  Eckstein2  and 
Meyer,3  while  cases  of  rupture  through  the  scar  of  the  ordinary 
longitudinal  incision  have  been  reported  by  Targett,  Galabin, 
Guillaume  Woyer,  Koblanck,  Everke,  Backhaus,  etc.,  and  recently 
by  Couvelaire,1  who  gives  a  review  of  several  of  the  recorded  cases. 

But  other  injuries,  such  as  perforation  of   the  uterus  with  the 

1  Journ.  Obstct.  and  Gyn.  Brit.  Enqrire,  1904,  vol.  vi.,  p.  378. 

2  Zent.f.  Gyn,,  1904,  p.  1302.  3  Ibid.,  1903,  p.  1416. 
4  Ann.  de  Gyn.,  1906,  p.  148. 

616 


RUPTURE  OF  THE  UTERUS  617 

curette  or  uterine  sound,  etc.,  have  been  followed  by  rupture  at  a 
subsequent  pregnancy,  as  in  the  cases  of  Herzfeld1  and  Staude.2 

In  this  connexion  the  observations  of  Jellinghaus,3  that  previous 
removal  of  an  adherent  placenta  predisposes  to  rupture,  are  of 
particular  interest.  The  probability  is,  that  in  such  cases  the 
operator  actually  tears  the  uterus  with  his  fingers  in  removing  the 
after -birth,  and  blood  being  effused,  the  wound  heals  by  granula- 
tion. 

Very  similar  to  the  above  are  those  in  which  a  previous  rupture 
gives  way.  Several  cases  of  this  nature  are  referred  to  in  Peham's 
monograph,4  and  by  Lahhardt.5 

Lastly,  there  is  a  group  in  which  injuries,  falls,  blows,  etc.,  during 
pregnancy  have  been  the  cause.  Reusing0  describes  a  case  of  his 
own  and  several  others  previously  recorded.  In  most  of  them  the 
women  were  multiparas,  but  in  Reusing's  and  Plenio's  cases  they  were 
young  primiparre.  The  injury  to  the  uterus  was  in  some  cases  direct, 
but  in  others  it  was  indirect,  the  women  having  fallen  upon  their  sides 
or  buttocks.  In  such  cases  the  laceration  is  generally  in  the  upper 
part  of  the  uterus,  and  is  very  extensive. 

As  is  well  known,  it  occasionally  happens  that  the  interstitial 
portion  of  the  tube  becomes  gravid,  and  ruptures,  as  a  rule,  about 
the  sixteenth  week.  Such  cases,  literally  speaking,  are  examples  of 
uterine  ruptures,  but  they  are  considered  in  Chapter  XXXII.  in  con- 
nexion with  ectopic  pregnancy.  The  same  applies  also  to  pregnancy 
in  a  rudimentary  horn  of  a  double  uterus. 

The  cases  of  rupture  of  an  infantile  uterus  in  which  pregnancy 
occurs  are  somewhat  different,  however.  Such  an  occurrence  is  very 
rare,  for  the  women  are  almost  invariably  sterile,  but  there  have 
been  described  one  or  two  cases  in  recent  years.  The  two  most 
interesting  are  those  of  Freund7  (Fig.  278)  and  Schickele,s  referred 
to  very  specially  by  Wertheim.9  Freund  considered  his  case  one  of 
pregnancy  in  an  infantile  uterus,  but  Schickele  looked  upon  his 
as  possibly  a  pregnancy  in  a  diverticulum.  Similar  are  the  cases, 
such  as  Donald's,10  already  figured  (p.  301),  where  a  double  uterus 
gave  way. 

By   putting   aside   all    such    cases,   which   are,   after   all,   easily 

1  Zent.  f.  Gyn.,  1901,  p.  1219.  2  Ibid.,  1903,  p.  706. 

3  Archivf.  Gyn.,  1897,  Bd.  liv.,  p.  103. 
*  Zent.f.  Gyn.,  1902,  p.  87. 

5  Zeit.f.  Geb.  u.  Gyn.,  Bd.  liii.,  p.  478. 

6  Zent.f.  Gyn.,  1895,  p.  41. 

7  Hegar's  '  Beitrage,'  iv.,  p.  1.  8  Ibid.,  1904,  viii.,  Heft  2. 
3  Winckel's  'Handbuch,'  Bd.  ii.,  Teil  i.,  p.  408. 

10  Practitioner,  June,  1903. 


618 


OPERATIVE  MIDWIFBKY 


explained,  and  also  those  such  as  Martin's,1  where  a  hydatidiform 
mole  perforated  the  uterine  wall,  there  yet  remains  a  number  in  which 
the  cause  of  rupture  is  still  unknown.  Hound  such  cases  there  is 
much  interesting  speculation.  As,  however,  the  suhject  belongs  still 
to  the  region  of  speculation,  I  do  not  intend  to  do  more  than  mention 
some  of  the  views  which  have  been  expressed. 


Fig.  278.— Fundal  Rupture  of  Infantile  Uterus.     (After  Freund.) 

Fatty  degeneration  has  been  freely  spoken  of  in  the  past,  but  in 
recent  years  grave  doubts  have  been  expressed  regarding  the  frequency 
of  its  occurrence  :  Herman,2  Gebhard,:i  and  other  modern  writers,  are 
very  sceptical   regarding   it.     Further   investigations   are   necessary 

1  Trans.  Edin.  Obst.  Soc,  vol.  xxi.,  p.  63. 

2  Trans.  Lond.  Obst.  Soc,  1901,  vol.  xliii.,  p.  220. 

3  '  Pathologische  Anatomie  TVeiblichen  Sexualorganen,'  1899,  p.  239. 


RUPTURE  OF  THE  UTERUS  619 

before  this  matter  is  decided.  The  same  also  applies  to  hyaline 
degeneration,  although  in  this  connexion  a  case  recently  recorded  by 
Meyer1  is  of  great  importance  and  interest.  He  found  in  the  neigh- 
bourhood of  the  tear,  which  had  occurred  during  pregnancy,  that  the 
uterine  tissue  and  muscle  showed  signs  of  hyaline  degeneration.  The 
exact  effect  of  pregnancy  on  a  uterus  affected  by  chronic  metritis  is 
also  unknown,  although  this  disease  has  been  mentioned  repeatedly 
by  writers  as  favouring  rupture,  nor  is  it  to  be  wondered  at  that  it 
should.  Personally,  I  feel  convinced  that  degeneration  of  the  wall 
is  frequently  present  and  predisposes  to  the  accident,  for  a  slight 
fall  or  cough,  or  a  more  than  usually  violent  movement  by  the  child, 
have  been  the  only  apparent  exciting  causes  in  some  cases. 

The  recent  investigations  of  Pick,2  Ivanoff,3  Schaper,4  and  many 
others,  have  not  confirmed  the  theory  of  Dawidoff  and  Poroschin,5  that 
the  rupture  is  due  to  a  deficiency  of  elastic  fibres  in  the  tissue  of  the 
uterus  in  the  neighbourhood  of  the  rupture.  Several,  including 
Martin  and  Diihrssen,  have,  however,  found  the  elastic  fibres  diminish 
as  age  advances,  and  it  is  quite  probable  that  they,  in  common  with 
other  tissues,  become  altered  with  each  succeeding  pregnancy. 

The  situation  of  the  placenta  has  an  influence  in  different  ways. 
There  are  not  a  few  recorded  cases  of  rupture  of  the  uterus  associated 
with  placenta  prcevia.  Again,  the  tubal  orifice  being  a  weak  spot,  as 
Gebhard  points  out,  \  implantation  there  is  favourable  to  rupture. 
Lastly,  in  a  considerable  number  of  cases  of  rupture  during  preg- 
nancy of  a  cicatrix  of  a  previous  Cesarean  section  wound,  the  placenta 
has  been  situated  over  the  cicatrix,  and  it  is  just  possible  that  under 
certain  conditions  the  chorionic  villi  have  a  specially  destructive  effect, 
and  burrow  unusually  deeply  into  the  wall.  Be  that  as  it  may,  not  a 
few  authors  have  referred  to  the  fact,  as,  for  example,  Alexandroff,6 
Meyer,  Couvelaire,  and  Eckstein.  I  also  refer  to  it  in  recording  my 
own  case  (p.  631). 

Rupture  of  the  Uterus  after  a  Protracted  Labour. 

It  might  appear  a  natural  sequence  that,  having  discussed  rupture 
during  pregnancy,  one  should  turn  to  those  cases  where  the  accident 
happens  early  in  labour.  Personally,  I  think  otherwise,  however,  for 
I  am  disposed  to  look  upon  the  latter  group  from  the  etiological  point 

1  Hegar's  'Beitrage,'  Bd.  ix.,  p.  45. 

2  Berlin.  Klinih  WochenscJirift,  1900,  xxiii. 

3  Annal.  de  Gijn.,  August,  September,  October,  1904. 

4  '  Diss.  Wurtzburg,'  1901. 

5  Zent.  f.  Gijn.,  1898,  p.  183. 

6  Monat.f.  Gel.  u.  Gyn.,  Bd.  xii.,  1900,  p.  447. 


620  OPEBATIVE  MIDWIFERY 

of  view,  as  standing  midway  between  the  group  where  rupture  occurs 
during    pregnancy   and   the   one   in    which    it   follows   a   prolon. 
parturition;  consequently,  it  will  be  beet  understood  after  these  groups 
have  been  considered. 

llupture  of  the  uterus  following  a  complex  and  protracted  labour 
is  a  subject  which  has  come  to  be  understood  only  in  recent  }rears. 
Although  Guilleineau.  Uaudelocque,  and,  later,  Michaelis,  appreciated 
in  great  part  the  nature  of  the  accident,  it  is  only  since  Bandl's 
writings  on  the  '  Lower  Uterine  Segment '  that  any  clear  conception 
of  the  pathological  anatomy  of  the  subject  has  arisen. 

For  a  correct  comprehension  of  rupture  of  the  uterus  in  labour 
one  must  appreciate  the  different  anatomical  features  of  the  uterus, 
and  especially  of  the  lower  segment,  during  parturition.  That  being 
so,  I  must  consider  them  for  a  moment. 

Since  Bandl's  paper  appeared  in  1875  the  number  of  contributions 
to  the  subject  of  the  lower  uterine  segment  have  been  legion,  but 
although  many  matters  regarding  it  have  from  time  to  time  been 
settled,  there  are  still  many  details  upon  which  differences  of  opinion 
exist,  and  these  differences  have  not  been  lessened  by  the  latest  frozen 
section  of  Bumm  and  Blumreich.  This  is  not  the  place  to  discuss 
these  in  detail,  and  so  I  have  thought  it  best  to  give  the  principal 
conclusions  of  one  of  the  most  recent  writers.  Von  Bosthorn,  writing 
in  YVinckel's  'Handbook  of  Midwifery,'1  comes  to  the  following  con- 
clusions regarding  the  lower  uterine  segment : 

1.  There  already  exists  during  pregnancy  a  lower  uterine  segment. 

2.  This  segment  is  covered  by  decidual  altered  mucous  mem- 
brane. 

3.  The  arrangement  of  the  muscle  in  the  wall  of  the  segment  is 
lamellar,  and  it  is  to  a  moderate  extent  distinct  from  the  wall  of  the 
corpus  uteri,  and  very  different  from  that  of  the  part  below. 

4.  The  upper  part  of  the  lower  segment  is  marked  by  the  firm 
attachment  of  the  peritoneum,  and  in  the  inside,  when  uterine 
contractions  have  already  been  in  existence  by  the  so-called  contrac- 
tion ring. 

5.  The  lower  limit  is  the  essentially  different  cervical  tissue. 

6.  The  mucous  membrane  appears  to  vary.  In  the  majority  of 
cases  there  is  sharp  differentiation — on  the  one  side  distinct  cervical 
mucous  membrane. 

The  illustration  represents  (Fig.  279)  the  relationship  of  the  different 
parts  of  the  uterus  during  parturition.  This  is  a  very  old  diagram- 
matic figure  of  Schroeder,  but  for  practical  purposes  it  is  still  useful. 
I  do  not  suppose  it  is  correct,  but  who  can  say  what  exactly  is  the 

1  Bd.  i.,  Heft  1.,  p.  5r,:\. 


RUPTURE  OF  THE  UTERI'S 


021 


lower  uterine  segment  ?  The  upper  part  or  body,  the  active  contrac- 
tile portion,  the  middle  or  lower  uterine  segment,  and  the  lower  part, 
the  dilated  cervix,  are  represented.  Daring  labour  the  upper  part,  the 
body,  is  the  only  really  active  part  of  the  uterus — it  alone  forces  the 
child  down  through  the  parturient  canal ;  the  lower  uterine  segment 


Fig.  279. — Diagrammatic  Representation  of  Parturient  Canal  at  End  of  First  Stage. 

(Schroeder.) 

and  cervix  play  an  entirely  passive  role.  As  labour  progresses  the 
body  becomes  diminished  in  a  vertical  direction  because  the  retraction, 
or  Bandl's,  ring,  which  marks  the  lower  limit  of  the  body  and  the 
upper  limit  of  the  lower  segment,  becomes  farther  and  farther  drawn 
up ;  it  can  be  appreciated  sometimes  by  abdominal  palpation  as  high 
as,  or  even  above,  the  umbilicus.     But  the  active  contractions  of  the 


622  OPERATIVE  .MII>\VI J'Kl:V 

uterus  would  do  more  than  pull  up  Bandl's  ring  ;  they  would  also 
pull  up  the  cervix,  were  it  not  that  the  latter  is  more  or  less  fixed  by 
its  attachments.  As  a  result,  therefore,  of  the  upper  part  being 
increasingly  retracted  and  the  lower  fixed,  one  finds,  in  a  protracted 
labour,  that  the  area  between — viz.,  the  lower  uterine  segment — 
becomes  more  and  more  stretched  and  thinned  out.  It  is  not 
surprising,  therefore,  that  there  is  a  stage  at  which,  not  being  able  to 
stretch  any  farther,  and  with  its  tissues  bruised  by  pressure  between 
the  head  and  the  pelvis,  it  gives  way,  either  spontaneously  or  as  a 
result  of  operative  interference. 

For  many  years  after  Bandl's  papers  great  importance  was 
attached  to  this  fixation  of  the  lower  part  of  the  uterus,  more 
particularly  by  the  presenting  head,  as  in  cases  of  contracted  pelvis 
and  hydrocephalus.  Freund,  at  the  present  time,  is  the  strongest 
supporter  of  this  view,  and  gives  emphatic  expression  to  it  in  his 
chapter  in  Winckel's  'Handbuch.'1  But  few  go  as  far  as  Freund. 
Olshausen  and  Veit  (in  the  last  edition  of  their  text-book)  and  Ivanoff 
do  not  attach  the  same  importance  to  this  factor.  Personally,  my 
experience  leads  me,  in  common  with  most  others,  to  side  with  the 
authorities  last  mentioned. 

"Without  doubt  a  good  deal  of  misunderstanding  has  arisen  from 
the  erroneous  idea  that  the  cervix  is  drawn  up  or  retracted  over  the 
head  during  labour.  From  clinical  observation  I  have  not  found 
that  to  be  the  case  to  any  great  extent,  and  the  records  of  frozen 
sections  support  that  view.  Barbour'2  points  this  out  when  he  says  : 
'  The  dilatation  of  the  cervix  can  only,  to  a  very  slight  degree,  result 
from  stretching  through  traction  on  its  ring  by  the  contracting 
uterine  walls,  but  must  be  almost  entirely  due  to  dilatation  through 
expansion  of  the  ring  by  the  bag  of  membranes  or  presenting 
part.' 

When  I  mentioned  before  that  the  cervix  was  fixed,  I  meant  that 
it  was  fixed  by  its  attachments,  not  by  the  presenting  part. 

What  happens  is  that  the  cervix  and  lower  part  of  the  lower  uterine 
segment  become  unduly  pressed  upon,  bmised,  and  lacerated.  It  is  not 
so  much  that  the  cervix  is  held  down  and  cannot  retract  over  the  head. 

But  let  us  now  consider  the  conditions  which  chiefly  favour  the 
occurrence  of  rupture  of  the  uterus — pelvic  deformity,  malpresenta- 
tions  and  malpositions  of  the  child,  and  hydrocephalus — and  let  us  see 
how  they  act  and  the  nature  of  the  injuries  they  produce. 

The  importance  of  pelvic  deformity  as  a  cause  of  rupture  of  the 
uterus  is  well  illustrated  by  the  large  percentage  of  cases  in  which 
bony  deformity  of  the  canal  exists.     In  seventeen  cases  which  have 

1  Bd.  ii.,  Teil  iii..  p.  '21  L6.  2  'Anatomy  of  Labour,'  p.  47. 


EUPTUEE  OF  THE   UTEEUS  623 

been  under  my  care  in  recent  years  pelvic  deformity  was  present 
in  50  per  cent. ;  others  have  had  a  similar  experience.  Merz 1  found 
it  in  30  per  cent.,  and  Ivanoff  in  40  per  cent,  of  their  collected  cases. 

The  pelvic  deformity  is  not,  as  a  rule,  of  the  extreme  type,  for 
when  the  deformity  is  great  the  danger  of  the  condition  is  early 
appreciated,  and  labour  is  not  allowed  to  be  indefinitely  protracted. 
Almost  without  exception  the  women  have  borne  children,  and  many 
of  them  have  had  several.  Naturally,  the  danger  increases  with  each 
succeeding  pregnancy.  This  is  often  attributed  to  degeneration  of  the 
uterus,  and  rightly  so  in  many  cases ;  but  in  recent  years  it  has  come  to 
be  recognized  that  in  some  cases  cicatrices  from  previous  labours  have 
given  way,  cicatrices  of  wounds  often  only  slight  and  never  appreciated. 
The  nature  of  the  lesion  in  the  different  forms  of  contracted  pelvis  has 
been  most  carefully  investigated  by  Ivanoff;  no  one  has  gone  into 
this  subject  so  particularly.  Personally,  however,  I  am  not  in  a 
position  to  express  any  opinion  regarding  his  conclusions,  for  although, 
in  common  with  others,  I  have  found  the  lesions  in  cases  of  contracted 
pelvis  are  in  general  as  he  has  described,  I  cannot  give  exact  state- 
ments. He  is  the  first  who  has  so  exactly  distinguished  the  lesions 
which  are  found  in  flat  pelvis  from  those  which  arise  in  generally 
contracted  pelvis.  He  believes  tha^the  tears  are  produced  by  injury 
of  the  soft  parts.  The  extension  of  the  rupture  may  occur  spontane- 
ously, or  be  produced  by  violence. 

With  these  lacerations,  which  occur  in  the  progress  of  labour 
transverse  commonly  in  front  or  behind  in  the  case  of  flat  pelvis,  and 
lateral  in  the  case  of  generally  contracted  pelvis,  extension  of  the  tear 
readily  occurs,  especially  if  the  child  is  forcibly  extracted.  In  such 
cases,  as  with  violent  rupture  in  general,  the  extension  of  the  lacera- 
tion is  often  longitudinal,  and  very  usually  passes  into  the  broad  liga- 
ment. In  the  Glasgow  Maternity  Hospital  during  the  last  twelve  years, 
amongst  the  cases  of  flat  pelvis  where  rupture  occurred  there  were 
four  in  which  the  child  was  delivered  with  forceps,  and  the  tear  pre- 
sented the  appearance  shown  in  the  illustration  (Fig.  280).  In  these 
cases  the  rupture  was  complete. 

Next  in  order  of  frequency  as  a  cause  of  rupture  are  malpresenta- 
tions  of  the  child,  and  especially  transverse  presentation.  Amongst 
my  cases  such  a  condition  existed  in  16  per  cent.,  and  taking  the 
authorities  already  referred  to,  one  finds  that  Koblanck  found  it  in 
25  per  cent.,  Merz  in  11  per  cent.,  and  Ivanoff  in  32  per  cent.  As 
might  be  expected,  the  rupture  in  most  cases  results  when  version  is 
attempted  after  the  waters  have  drained  away  and  the  shoulders  have 
become  impacted.      But  in  a  certain  number  of  cases  this  has  not 

i  Archivf.  Gyn.,  1894,  Bd.  xlv.,  Heft  2.,  p.  181. 


624 


OPERATIVE  MIDWIEEllY 


been   so :    the   rupture   has  .occurred   spontaneously.      Spontaneous 
rupture  in  transverse  presentations,  however,  is  rare. 

In  most  cases  the  laceration  is  longitudinal  and  to  one  or  other 


FlG.  280, — Laceration  of  the  Posterior  Uterine  Wall  in  a  Case  of  Flat  Pelvis. 


side  (Fig.  281).  It  tends  to  be  extensive,  as  one  would  expect,  and  to 
run  up  into  the  body.  The  cervix  is  invariably  torn,  and  the  vaginal 
vault  in  many  cases  also  suffers.      In   this   condition   there   is   no 


RUPTURE  OF  THE  UTERUS  625 

difficulty  in    understanding   how  the  accident  occurs;    indeed,  it   is 
Surprising  that  it  does  not  occur  oftener. 

Other  nialpresentations,  such  as  face  and  brow  presentations,  are 
Dccasionally  found  associated  with  rupture.     A  brow  presentation  is 


Fig.  281. — Laceration  of  the  Lateral  and  Posterior  Uterine  "Wall. 

jertainly  a  very  unfavourable  attitude,  for  the  long  diameter  is  thrown 
icross  the  pelvic  brim  (p.  44).  It  is  dangerous,  therefore,  to  attempt 
,o  deliver  the  child  by  forceps.  Indeed,  should  such  a  course  be 
persisted  in  after  one  or  two  futile  attempts,  the  risks  of  rupture  are 
:onsiderable.      Very  much  less  likely  to  cause  injury  are  face  and 

40 


626  OPERATIVE  MIDWIFERY 

occipito-posterior  vertex  presentations ;  when  they  are  associated  with 
rupture,  the  cause  has  usually  been  some  coexisting  condition,  or  the 
manipulations  have  been  badly  carried  out. 

The  other  important  cause  of  rupture  is  hydrocephalus.  In  my 
seventeen  cases  it  occurred  once  (6  per  cent.),  while  Merz  found  it  in 
7*5  per  cent.,  and  Ivanoff  in  3  per  cent.  In  most  cases  of  rupture  pro- 
duced by  hydrocephalus,  however,  the  hydrocephalus  has  not  really 
been  the  cause  :  either  the  condition  has  not  been  recognized — and  it 
must  not  be  forgotten  how  easy  it  is  to  overlook  the  condition — or  the 
proper  treatment — craniotomy — has  not  been  practised  ;  attempts  have 
been  made  with  forceps,  as  in  my  case,  or  some  other  method  of  delivery 
has  been  tried.  As  a  cause  of  rupture  in  this  condition,  Freund 
attaches  great  importance  to  the  fixation  of  the  cervix  by  the  enlarged 
head.  He  believes  this  occurs  more  frequently  when  the  hydro- 
cephalus is  of  medium  dimensions,  as  when  it  is  very  large  the  head 
cannot  engage,  and  so  the  cervix  slips  over  the  head.  Ivanoff  attaches 
more  importance  to  bruising  of  the  tissues.  The  lacerations  are,  as  a 
rule,  very  extensive  and  longitudinal.  In  my  case  the  whole  lateral 
wall  was  torn  longitudinally. 

Other  conditions,  such  as  tumours,  cicatrices  and  adhesions,  etc., 
obstructing  the  parturient  canal,  may  naturally  predispose  to,  and 
may  be  occasionally  associated  with,  rupture.  Old  cicatrices,  es- 
pecially about  the  cervix,  are  liable  to  tear,  although  sometimes  the 
cicatricial  tissue  withstands  the  strain,  and  the  tissues,  not  involved 
formerly,  give  way.  With  tumours  the  accident  should  not  occur,  as 
it  is  now  recognized  that  it  is  quite  inexcusable  to  drag  a  child  past  a 
tumour  by  brute  force. 

In  a  certain  number  of  cases  rupture  has  followed  the  removal  of 
the  placenta.  Schwendener1  has  recorded  one  as  a  result  of  expelling 
the  placenta  after  Crede's  method.  Fraenkel1  has  recorded  another. 
Oswald2  has  collected  thirty-eight  cases  from  obstetric  literature 
where  it  wTas  produced  while  manually  removing  the  placenta.  Twice 
while  removing  an  adherent  placenta  situated  at  the  fundus  I  have 
found  my  fingers  almost  through  the  uterine  wall,  an  experience 
which  has  led  me  to  exert  the  greatest  possible  care  in  performing 
this  simple  operation.  I  have  referred  elsewhere  to  the  dangers  of 
rupture  in  subsequent  pregnancies  when  the  uterine  wall  has  been 
injured  by  the  fingers,  curette,  or  uterine  sound. 

1  Zent.f.  Gyn.,  1903,  p.  907. 

2  Beitrdg.  z.  Geb.  u.  Gyn.,  Bd.  viii.,  Heft  1;  ref.  Zent.f.  Gyn.,  1904,  p.  336. 


RUPTURE  OF  THE  UTERUS  627 

Rupture  of  Uterus  Early  in  Labour. 

We  must  now  turn  to  the  last  and  most  interesting  group  of  cases 
— viz.,  those  in  which  rupture  occurs  early  in  labour. 

This  group,  as  regards  etiology,  stands  midway  between  the  two 
others,  for  rupture  results  partly  from  disease  of  the  uterine  wall,  and 
partly  from  the  conditions  mentioned  in  connexion  with  the  previous 
group. 

Personally,  I  cannot  but  feel  that  disease  of  the  uterine  wall,  and 
probably  unrecognized  lacerations  at  previous  labours,  play  the  most 
important  part,  for  looking  at  the  recorded  cases  one  is  struck  with 
the  frequency  of  previous  difficult  labours,  injuries,  or  disease.  Take 
the  case  described  by  the  late  Milne  Murray,1  where  there  had  been 
protracted  parturitions  and  possibly  the  wall  seriously  injured.  The 
various  diseased  conditions  which  may  exist  have  already  been 
referred  to  when  rupture  during  pregnancy  was  under  considera- 
tion. 

But  there  is  another  condition  which  specially  comes  into  play  in 
ruptures  of  this  group,  and  it  was  mentioned  years  ago  by  Bandl. 
The  lower  segment  may  have  been  overstretched  at  a  previous  labour, 
and  consequently  very  early  in  a  subsequent  one  reaches  the  same 
condition.  Some  of  the  records  would  lead  one  to  attach  some 
importance  to  this  view ;  naturally,  it  will  always  be  very  difficult  to 
distinguish  rupture  caused  by  such  a  condition  and  rupture  caused  by 
the  giving  way  of  a  previous  cicatrix. 

Freund  considers  that  even  rigidity  of  the  os  externum  may  bring  it 
about.  But  in  order  to  prove  that  rigidity  per  se  could  cause  rupture, 
one  would  require  to  satisfy  oneself  that  there  did  not  also  exist  de- 
generation of  the  uterine  muscle. 

It  is  not  to  be  wondered  at  that  occasionally  rupture  of  the  uterus 
should  be  associated  more  or  less  directly  with  placenta  praevia,  for  a 
placental  implantation  weakens  the  lower  uterine  segment,  and 
manipulations  to  arrest  haemorrhage,  such  as  turning,  which  en- 
danger the  lower  uterine  segment,  have  generally  to  be  had  recourse 
to.  All  authors  refer  to  the  occasional  association  of  the  two  com- 
plications :  in  my  list  there  was  one  case,  in  Ivanoffs  twelve. 
Ivanoff  very  rightly,  it  seems  to  me,  emphasizes  the  fact  that  in 
the  vast  majority  of  the  cases  rupture  was  violent.  Taking  twenty 
cases  from  his  own  and  collected  cases,  sixteen  were  certainly  violent, 
two  probably  violent,  and  only  two  spontaneous.  In  the  majority  of 
these  cases  the  laceration  was  lateral,  longitudinal,  and  incomplete. 
However,  spontaneous  rupture  does  occasionally  occur,  and   a   case 

1  Edin.  Obst.  Trans.,  1901,  vol.  xxvii.,  p.  39. 


028  OPERATIVE  MIDWIFERY 

was  recently  recorded  where  the  accident  occurred  in  a  primipara. 
Absolutely  nothing  was  done  to  interfere  with  the  birth  of  the 
child  except  to  rupture  the  membranes  when  the  os  was  about 
three-quarters  dilated.  The  birth  of  the  child  quickly  followed. 
The  rupture  was  through  the  posterior  wall  of  the  uterus,  and  was 
apparently  incomplete. 


Varieties  of  Rupture  of  the  Uterus. 

Complete  and  Incomplete  Rupture. — Clinically,  it  is  customary 
to  speak  of  'complete'  and  'incomplete'  rupture  of  the  uterus.  By 
the  former  condition  we  mean  that  the  laceration  extends  into  the 
peritoneal  cavity,  and  by  the  latter  that  it  stops  short  of  the  peritoneum. 
This  distinction  is  very  useful,  for  we  shall  find  that  the  treatment 
differs  in  the  two  groups.  As  regards  the  relative  frequency  of  the 
two  varieties,  it  appears  from  most  series  of  cases  that  complete 
rupture  is  more  common  than  incomplete.  It  must  not  be  forgotten, 
however,  that  there  is  a  very  large  number  of  ca.ses  of  incomplete 
rupture  never  reported,  nor  indeed  appreciated,  while  few  of  the 
cases  of  complete  rupture  escape  notice,  seeing  that  the  symptoms 
are  more  grave.  Of  the  17  cases  of  rupture  under  my  care  in  private 
and  hospital  practice,  in  only  5  has  the  rupture  been  incomplete. 
Braun  gives  it  as  4  incomplete  and  15  complete ;  Merz  as  46  incom- 
plete and  181  complete;  Ivanoff  as  43  incomplete  and  58  complete. 
As  would  be  expected,  the  lower  down  in  the  uterus  and  the  more 
lateral  the  tea]',  the  more  likely  will  the  rupture  remain  incomplete. 
The  cases  of  laceration  during  pregnancy  or  early  in  labour  are,  with 
few  exceptions,  complete. 

Amongst  the  cases  which  have  been  under  my  care,  in  one  only 
have  I  found  the  bladder  involved.1  In  Braun' s  nineteen  cases  there 
was  only  one  in  which  the  bladder  was  injured.  Neither  in  Merz's 
nor  Ivanoff' s  collected  cases  can  I  find  any  evidence  of  laceration  of 
the  bladder.  In  Murray's  most  interesting  case  the  bladder  was  torn 
and  had  to  be  stitched. 

There  is  a  veiy  interesting  group  of  cases  in  which  the  mucous 
membrane  of  the  uterus  remains  intact,  although  the  muscular  wall 

1  Rupture  of  bladder,  apart  from  rupture  of  uterus  and  retrodisplacenient  of  the 
gravid  uterus,  is  very  rare.  Grhnsdale  (Journ.  Obst.  ami  Gyn.  Brit.  Empire,  May, 
1905)  has  referred  to  a  most  interesting  case  in  which  the  bladder  was  injured  in 
the  first  stage  of  labour.  On  opening  the  abdomen  a  large  quantity  of  blood  was 
found  in  the  peritoneal  cavity.  This  had  escaped  from  the  bladder  through  a  small 
opening  in  its  upper  part.  The  opening  was  closed,  and  the  patient  made  an 
excellent  recovery. 


RUPTURE  OF  THE  UTERI'S  629 

is  torn.  The  point  of  importance  in  these  cases  is  that  there  are 
all  the  symptoms  of  collapse  from  internal  haemorrhage  without  any 
appreciable  lesion  of  the  uterus  or  vagina.  Knauer  has  drawn  atten- 
tion to  the  subject  recently.1  In  such  cases  the  tears,  starting  in  the 
muscle,  may  extend  either  outwards  or  inwards.  Slight  tears  of  the 
peritoneum  (fissures  of  the  peritoneum)  over  the  surface  of  the 
upper  part  of  the  uterus  have  long  been  known  to  occur,  and 
have  been  frequently  referred  to  by  different  obstetric  writers.  This 
laceration  of  the  muscular  tissue,  however,  has  not  had  attention 
directed  to  it.  Of  especial  interest  are  Knauer's  observations  in  con- 
nexion with  concealed  accidental  haemorrhage.  In  several  of  these 
cases  he  observed  laceration  of  the  muscular  wall  with  considerable 
intramural  haemorrhage.  I  observed  the  same  condition  of  matters 
in  a  fatal  case  of  concealed  haemorrhage  which  was  under  my  care  in 
the  Maternity  Hospital. 

Rupture  of  the  Vaginal  Vault  (Colporrhexis).  —  In  recent 
years  the  subject  of  rupture  of  the  vaginal  vault  (colporrhexis — 
Fig.  282),  as  distinguished  from  rupture  of  the  uterus,  has  been  much 
discussed.  This  lesion  is  no  new  discovery ;  indeed,  before  Bandl's 
papers  lesions  of  this  nature  were  understood  better  than  lacerations 
of  the  uterus.  But  after  Bandl's  papers  lacerations  of  the  vaginal 
vault  were  neglected  for  uterine  rupture,  until  Freund 2  reawakened 
interest  in  the  subject.  In  recent  years  the  most  important  paper 
is  one  by  Kaufman,3  who  discusses  the  subject  very  fully. 

Specially  liable  to  this  form  of  rupture  are  cases  of  transverse 
presentation  and  pendulous  abdomen.  Generally  the  rupture  is 
violent,  and  often  occurs  when  the  hand  is  being  forced  into  the 
uterus.  But  Kaufman,  in  his  collected  cases,  quotes  many  that 
were  not  violent,  and  were  the  result  of  a  diseased  condition  of  the 
tissues,  and  of  other  factors.  Where  only  the  vaginal  vault  is  torn 
there  may  be  no  symptoms  of  consequence.  Plugging  is  generally 
the  best  treatment. 


Symptomatology  and  Diagnosis. 

The  clinical  features  of  rupture  of  the  uterus  differ  greatly 
according  as  the  rupture  occurs  in  pregnancy,  early  in  labour,  or  after 
labour  has  been  in  progress  for  some  time.  In  the  two  former  there 
is  seldom  much  warning  of  the  accident,  while  in  the  latter  very 

1  Zent.f.  Gyn.,  1903,  p.  647. 

2  Zeit.f.  Geb.  u  Gyn.,  1S92,  Ed.  xxiii.,  Heft  2. 

3  Archivf.  Gyn.,  1908,  Bd.  lxviii.,  Heft  1,  p.  152. 


630 


OPERATIVE  MIDWIFEKY 


frequently,  for  some  little  time  before,  there  are  premonitory  symp- 
toms, which  if  properly  interpreted  by  the  accoucheur  should  lead 
him  to  dread  rupture,  and,  consequently,  to  take  every  precaution  to 
prevent  it. 

Taking  first  the  cases  where  the  rupture  occurs  early  in  labour 
or  during  pregnancy,  one  Mould  naturally  expect,  as  with  rupture  of 
any  other  viscus,  that  the  giving  way  of  the  uterus  would  be  followed 


Fig.  282. — Laceration  of  the  Lower  Part  of  the  Uterus  and  the  Vaginal  Vault. 
The  uterus  is  turned  over  to  the  right  to  show  the  laceration. 

immediately  by  severe  abdominal  pain,  decided  collapse,  and  other 
symptoms  of  internal  haemorrhage,  small  thready  pulse,  cold  sweats, 
etc.  "Without  doubt,  in  many  cases  these  symptoms  are  present, 
and  the  nature  of  the  condition  is  self-evident,  but  what  is  not 
fully  appreciated  is  that  sometimes  they  are  not  evident  and  the 
accident  is  overlooked.  Here  is  a  case  from  my  own  practice 
which  illustrates  how  very  gradual  the  onset  of  the  symptoms 
may  be : 


KUPTUEE  OF  THE  UTERUS  631 

Spontaneous  Rupture  of  the  Uterus  chiving  Pregnancy  through  the  Cicatrix  of 

a  Ccesarean  Section  Wound. — Mrs.  M ,  3-para,  was  admitted  on  October  28, 

1901,  to  the  Glasgow  Maternity  Hospital.  In  both  the  previous  labours 
the  children  were  extracted  with  difficulty,  and  were  dead.  On  the  last 
occasion  craniotomy  had  to  be  performed.  The  pelvis  was  of  the  flat 
rachitic  type,  the  diagonal  conjugate  being  3f  inches.  I  therefore  chose 
Csesarean  section,  and  employed  the  '  fundal  incision '  of  Fritsch.  I  came 
right  down  on  the  placenta,  which  I  removed  before  extracting  the  child. 
The  child,  which  weighed  eight  pounds,  was  extracted  very  easily,  and 
the  uterine  wound  stitched  with  little  trouble  or  bleeding.  She  was  not 
sterilized.  The  temperature  was  never  above  normal,  and  the  pulse,  after  the 
first  three  days,  was  not  accelerated.  The  abdominal  wound  healed  by  first 
intention,  the  stitches  being  taken  out  on  the  fourteenth  day.  The  patient 
left  hospital  on  November  30,  both  she  and  her  baby  being  perfectly  well. 

The  following  note  was  made  on  her  admission  for  the  second  Csesarean 
section  on  January  26,  1904  :  As  far  as  can  be  judged  the  patient  is  now  in 
her  thirty-seventh  week  of  pregnancy ;  she  has  been  in  good  health,  and 
has  suffered  no  special  discomfort  since  she  became  pregnant.  She  is  well 
nourished  and  of  good  colour ;  her  pulse  is  of  good  tension,  regular  in  force 
and  rhythm,  and  numbers'  84  per  minute.  The  abdomen  is  irregularly 
enlarged,  the  bulk  of  the  swelling  being  to  the  right  side.  There  is  a 
median  firm  scar  of  the  previous  Cesarean  section.  Foetal  movements  are 
active.     The  cervix  is  not  taken  up,  but  admits  the  tip  of  one  finger. 

After  an  enema,  given  about  midnight,  the  patient  complained  of 
abdominal  discomfort  —  slight  pain  in  the  epigastrium  ;  this  extended 
upwards  and  to  the  right.  She  mentioned  this  to  the  night-nurse,  but 
as  she  did  not  complain  further  and  fell  asleep,  the  nurse  did  not  think  it 
necessary  to  report  the  fact  to  the  house-surgeon.  She  slept  from  about 
12.30  till  5  a.m.,  at  which  time  a  sanguineous  discharge  from  the  vagina  was 
noticed,  and  slight  pain  in  the  right  iliac  region  was  complained  of.  At 
7  a.m.  the  temperature  was  97*6°  F.,  and  the  pulse  80 ;  the  pain,  which  had 
now  spread  over  the  abdomen,  was  not  very  great,  so  it  was  taken  for 
painful  uterine  contractions.  There  was  no  sickness  or  vomiting.  At 
11  a.m.,  on  making  my  ward  visit,  I  spoke  to  the  patient  quite  by  chance, 
for  no  one  considered  her  condition  serious.  I  then  found  that  there  was 
considerable  abdominal  tenderness,  and  suggested  to  those  present  the 
possibility  that  the  old  uterine  cicatrix  had  given  way.  As,  however,  the 
pulse  was  84,  regular,  and  of  good  tension,  I  simply  advised  my  house- 
surgeon,  Dr.  Rodgers,  to  go  into  the  case  and  note  the  patient's  condition 
carefully.  An  hour  afterwards  I  was  summoned  by  him,  as  the  abdominal 
tenderness  was  now  more  marked,  the  pulse  90,  the  temperature  sub- 
normal, and  the  breathing  more  rapid.  At  this  time  the  condition  of  the 
abdomen  was  as  follows  :  She  lay  with  her  feet  slightly  drawn  up ;  on 
palpation  there  was  considerable  tenderness  over  the  whole  abdomen,  more 
marked  to  the  right  and  below  the  umbilicus ;  the  pain  also  extended  up  to 
the  right  shoulder.  On  placing  the  hand  over  the  abdomen  one  was  struck 
by  the  readiness  with  which  the  fcetal  parts  could  be  defined ;  above  the 


682 


o|'i:i;ati\j;  midyyii-kky 


umbilicus,  and  slightly  to  the  left  of  the  middle  line,  a  limb  could  be  made 
outj  while  the  head  lay  towards  the  left  iliac  fossa.  Two  tumours  could  not 
be  differentiated;  percussion  gave  a  slightly  dull  note  in  the  Banks.  On 
vagina]  examination  the  tip  of  one  finger  could  be  pushed  through  the 
cervix,  but  the  presenting  pari  could  not  be  felt  ;  on  withdrawing  the  finger 
it  was  blood-stained.     The  pulse  numbered  <v>s 

•  Strychnine  .,',,  grain  was  given,  and  the  patient  prepared  for  laparotomy. 
She  was  anaesthetized,  and   the  abdomen    opened   along   the  side   of    the 


/ 


Fig.  283. — Rupture  of  Uterus  through  the  Cicatrix  of  a  Previous  Csesarean  Section 
"Wound.     (Author's  Case.) 

previous  incision.  Immediately  that  was  done  a  large  quantity  of  dark- 
coloured  blood  escaped,  and  the  intact  membranes  and  placenta  with  the 
enclosed  foetus  presented.  The  uterus  lay  retracted  behind  and  down 
towards  the  pelvis.  The  membranes  were  opened  into  and  a  well-formed 
dead  child  extracted.  The  uterus  was  then  examined  and  a  transverse 
rupture  was  found  extending  over  the  highest  part  of  the  fundus  (Fig.  283), 
evidently  through  the  cicatrix  of   the   wound   of  the   previous   Csesarean 


RUPTURE  OF  THE  UTERUS  633 

section.  There  were  only  two  slight  uterine  adhesions,  one  to  the  omentum 
and  one  to  the  abdominal  wall.  The  uterus  was  removed  by  supravaginal 
hysterectomy,  the  peritoneum  being  carefully  brought  over  the  stump. 
Finally,  all  blood-clot  was  removed,  and  fully  2  pints  of  saline  solution 
Avere  introduced  into  the  peritoneal  cavity.  After  the  operation  the  patient 
was  considerably  collapsed  ;  the  lips,  cheeks,  and  extremities  were  blanched ; 
the  pulse  was  126,  small,  easily  obliterated,  but  regular.  She  soon  im- 
proved, however ;  the  following  day  the  pulse  was  1 20  and  the  tempera- 
ture 98°  F.     She  was  dismissed  a  month  after  the  operation  perfectly  well. 

Sooner  or  later  in  almost  all  cases  symptoms  arise  :  the  woman 
complains  of  increasing  abdominal  pain.  She  assumes  more  decidedly 
the  '  abdominal  facies,'  while  a  most  important  feature  is  the  steady 
increase  in  the  pulse-rate. 

As  far  as  I  have  been  able  to  find  from  records  of  cases,  this 
'  quiet :  rupture  rarely  occurs  in  cases  of  spontaneous  rupture  early  in 
labour  ;  in  all  such  cases  the  classical  symptoms  of  rupture  are  present. 
and  there  is  no  difficulty  in  diagnosing  the  fact  that  the  uterus  has 
given  way.  The  same  also  applies,  although  not  quite  so  universally, 
to  rupture  in  pregnancy  when  that  accident  follows  any  fall  or  strain. 
The  cases  in  which  the  quiet  rupture  occasionally  takes  place  are  where 
the  uterus  is  diseased  or  has  been  previously  injured.  In  such  the 
•ovum  seems  to  pass  gradually  through  the  uterine  tear.  Not  in- 
frequently the  placenta  is  situated  over  the  tear  ;  quite  a  number  of 
writers  have  called  attention  to  this  fact. 

An  interesting  case  in  which  rupture  was  found  in  progress  was 
the  one  recorded  by  Staude.1  Early  in  labour  a  small  elastic  tumour 
developed  over  the  anterior  wall  of  the  uterus  during  the  pains.  The 
condition  was  diagnosed  as  a  rupture,  the  abdomen  was  opened,  and 
the  diagnosis  confirmed. 

But  after  all,  rupture  of  the  uterus  during  pregnancy  or  early  in 
labour  is  not  a  condition  which  is  often  encountered,  and  is,  con- 
sequently, not  a  subject  upon  which  one  is  justified  in  lingering.  We 
must  therefore  turn  to  the  cases  which  form  the  bulk  of  the  examples 
of  rupture  of  the  uterus — those  in  which  the  tear  occurs  late  in  labour 
or  during  attempts  at  delivery. 

In  considering  cases  of  this  nature  it  is  customary  to  discuss  the 
symptomatology  before  and  after  rupture.  This  is  a  wise  procedure, 
for  in  a  large  proportion  of  cases  there  are  distinct  premonitory 
symptoms. 

After  a  prolonged  second  stage,  where  the  expulsive  forces  are  not 
at  fault,  the  patient  becomes  restless  and  complains  of  constant  pain 
over  the  lower  part  of  the  uterus,  while  the  uterine  contractions  tend 

i  Zent.f.  Gyn.,  1904,  p.  781. 


634  OPERATIVE  Mll>\\  I  l'KHY 

to  become  more  and  more  tetanic.  Id  addition,  the  pulse  becomes 
more  rapid  and  the  temperature  possibly  rises  slightly.  Along  with 
these  symptoms  there  is  a  steady  increase  of  the  lower  uterine 
segment.  This  can  be  easily  appreciated,  for  the  retraction  or 
Bandl's  ring  can  be  felt  to  rise  higher  and  higher.  There  is  seldom 
any  difficulty  in  palpating  the  ring,  for  it  can  be  appreciated  as  a  hard 
ridge  round  the  uterus.  I  have  seen  it  as  high  as  the  umbilicus. 
It  is  not  always  at  the  same  level  all  round  ;  especially  is  this  seen 
in  cases  of  transverse  presentation,  where  one  part  is  subjected  to 
greater  strain  than  the  other.  One  can  often  appreciate  that  the  wall 
of  the  segment  is  very  thin,  but  as  a  rule  it  is  so  tense  and  tender 
that  the  foetal  parts  cannot  be  differentiated.  With  a  uterus  in  such 
a  state  rupture  may  occur  at  any  time. 

How  general  such  symptoms  are  prior  to  rupture  I  have  not  had 
opportunities  of  judging,  for,  wTith  one  exception,  the  patients  have 
come  under  my  care  after  the  rupture  has  occurred.  From  what 
I  have  been  able  to  gather,  however,  in  many  cases  they  were 
present,  and  I  have  frequently  seen  them  and  feared  rupture.  "When 
a  patient  in  such  a  condition  comes  under  one's  care,  no  attempts 
to  deliver  by  version  or  forceps  should  be  made  ;  decapitation  or 
craniotomy  should  be  immediately  performed. 

Turning  now  to  the  symptoms  which  follow  rupture,  it  is  a  very 
striking  fact  that  in  a  large  number  of  cases  the  rupture  has  not  been 
recognized  until  after  the  birth  of  the  child.  The  classical  symptoms 
of  a  sudden  feeling  of  something  giving  way,  of  cessation  of  the 
uterine  contractions,  of  alteration  in  the  shape  of  the  abdominal 
swelling,  of  haemorrhage  and  collapse,  are  very  frequently  absent  ; 
nor  is  this  to  be  wondered  at,  for  in  many  cases  the  rupture  takes 
place  during  the  delivery.     Let  us  consider  these  symptoms  seriatim. 

In  very  few  indeed  of  my  cases  or  those  reported  by  Ivanoff 
and  others  has  the  symptom  of  a  sudden  feeling  of  something  having 
given  way  been  present,  and  naturally  it  cannot  be  expected  to  be 
appreciated  in  the  cases  of  rupture  from  violence,  for  the  patient  is 
then,  usually,  under  the  influence  of  the  anaesthetic.  "When  it  is 
present  the  laceration  is  extensive,  and  the  child,  in  whole  or  in  part, 
generally  escapes  into  the  peritoneal  cavity. 

The  same  remarks  apply  to  cessation  of  the  uterine  contractions. 
This  symptom  is  again  most  pronounced  where  the  child  escapes  into 
the  abdominal  cavity.  It  must  not,  of  course,  be  confused  with  the 
uterine  inertia  which  follows  exhaustion  of  the  uterine  muscle  ;  the 
latter  is  gradual  in  its  onset. 

It  is  hardly  necessary  to  say  that  an  alteration  in  the  shape  of  the 
abdominal  swelling  can  only  occur  if  the  child  passes  in  whole  or  in 


EUPTUEE  OF  THE  UTEEUS  635 

part  outside  of  the  uterus,  and  this,  we  have  seen,  does  not  occur 
so  often  as  is  supposed.  When  it  does  occur,  two  abdominal  swellings 
can  be  differentiated,  the  one  representing  the  parts  of  the  child  that 
have  escaped  and  the  other  the  retracted  uterus.  Naturally,  it  is  most 
distinct  when  the  child  and  uterus  lie  side  by  side ;  for  if  the  retracted 
uterus  is  placed  behind,  as  in  one  of  my  cases,  it  is  impossible  to  distin- 
guish the  two  swellings.  When  present  this  alteration  in  the  shape  of 
the  abdominal  swelling  is  a  symptom  of  great  importance,  especially  if 
the  accoucheur  has  observed  the  uterine  outline  beforehand. 

Occasionally  this  sign  is  present  in  other  conditions  than  rupture. 
Quite  recently  I  saw  a  case  of  dystocia  from  pelvic  deformity  in 
a  patient  with  a  bipartite  uterus.  The  double  swelling  of  the 
uterus  and  the  collapse  of  the  patient  led  me,  on  seeing  the  case  for 
the  first  time,  to  think  of  rupture  of  the  organ.  It  was  a  case 
of  accidental  haemorrhage. 

Similarly,  in  cases  of  plural  pregnancy,  the  uterine  outline  being 
often  irregular  and  double,  a  suspicion  of  rupture  of  the  uterus  may 
arise  if  the  patient  shows  any  evidence  of  collapse  during  labour. 
Again,  in  cases  where  there  is  a  coexisting  tumour,  either  ovarian 
or  uterine,  a  differential  diagnosis  has  occasionally  to  be  made  between 
such  a  condition  and  rupture  of  the  uterus.  But  a  difficulty  in 
differential  diagnosis  may  occur  in  a  much  simpler  and  more  common 
condition — viz.,  in  an  impacted  oblique  presentation,  for  then  there  are 
two  swellings  with  a  sulcus  between.  Sometimes,  when  such  cases 
are  brought  into  hospital  in  a  markedly  collapsed  condition,  we  have 
great  difficulty  in  deciding  if  rupture  has  occurred  or  not.  Indeed, 
often  it  is  only  possible  to  decide  by  an  intra-uterine  examination 
under  deep  anaesthesia. 

In  addition  to  an  alteration  in  the  outline  of  the  uterus,  the  foetal 
parts  become  much  more  easily  palpated,  after  the  child  has  escaped  into 
the  peritoneal  cavity.  One  must  be  very  careful  in  deciding  upon 
rupture  on  such  grounds,  for  sometimes  the  uterine  wall  is  so  soft 
and  thin  that  the  fcetal  members  are  felt  as  if  underneath  the  thin 
abdominal  parietes.  In  advanced  extra-uterine  pregnancy  the  child 
can  also  be  very  easily  palpated. 

The  amount  of  haemorrhage  which  occurs  as  a  result  of  rupture  of 
the  uterus  varies  very  greatly.  Amongst  my  own  cases  I  have  only 
had  three  in  which  it  was  extremely  severe.  Ivanoff,  in  his  long 
series  of  124  collected  cases,  found  only  53  in  which  the  haemor- 
rhage proved  fatal,  and  in  half  of  them  not  until  many  hours  after 
the  accident. 

One  may  be  deceived  in  respect  to  the  actual  quantity  of  blood  lost, 
for  a  considerable  amount  may  escape  into  the  peritoneal  cavity,  or 


636  OPERATIVE  MIDWIFERY 

into  the  cellular  tissue  around  the  uterus,  and  remain  concealed. 
Sometimes  the  bleeding  is  BurprisiDgly  small  in  amount.  The  reasons 
for  this  are  the  relative  situation  of  the  tear  to  the  larger  vessels  and 
the  fact  that  the  latter  do  not  tear  readily.  In  one  of  the  cases 
of  rupture  upon  which  I  operated — the  case  is  here  briefly  detailed — 
the  tear  was  along  the  side  of  the  large  uterine  artery,  which  could  be 
seen  pulsating,  but  only  the  smaller  veins  were  torn. 

of  Complete  Rupture  of  the  Uterus  with  Escape  oj  //'<<    Fcetm  into  the 

Peritoneal   Cavity    -Panhysterectomy      Recovery.1 — Mrs.   X ■,    2-para,     - 

twenty-four,  had  been  delivered  by  craniotomy  four  year*  before  her 
admission  to  the  Maternity  Hospital  on  March- 18,  11)07.  Present  labour 
came  on  at  term.  Attempts  at  delivery  with  forceps  failed,  after  which  she 
was  .sent  into  the  Maternity  Hospital  under  my  care.  When  I  saw  her  a  little 
time  after  her  admission  her  pulse  was  140,  and  she  was  evidently  ill,  but  not 
seriously  collapsed.  My  house-surgeon  informed  me  that  she  was  worse  than 
when  she  was  admitted.  There  was  no  history  of  sudden  pain,  or  of  anything 
having  'given  way.'  She  was  not  very  blanched.  I  could  feel  the  child 
free  in  the  abdominal  cavity.  From  the  vagina  I  could  feel  an  extensive  tear 
on  the  right  side  of  the  uterus  and  vaginal  vault.  There  was  no  profuse 
vaginal  hemorrhage.  Upon  opening  the  abdomen  I  found  the  foetus  free 
in  the  abdominal  cavity,  which  also  contained  meconium,  vernix  easeosa, 
liquor  amnii,  and  a  little  blood.  After  removing  the  child  and  placenta  I 
examined  the  rupture,  and  found  that  it  extended  vertically  through  the 
right  lateral  wall  of  the  lower  segment  and  transversely  in  front,  so  that 
only  a  small  portion  of  cervix  remained  attached  to  the  bladder.  The 
bladder  itself  was  not  injured.  I  clamped  and  then  divided  all  the  uterine 
attachments  and  removed  the  entire  uterus.  I  then  packed  the  lower  part 
of  the  pelvis  with  gauze  and  closed  the  abdomen.  The  whole  operation  did 
not  take  twenty-five  minutes.  The  patient  soon  got  over  the  shock.  The 
gauze  was  removed  by  the  vagina  on  the  fourth  day.  She  made  an  uninter- 
rupted recovery. 

I  have  already  emoted  IvanofT's  experience  and  my  own,  which 
agrees  with  it.  Eversmann2  states  that  only  in  some  12  to  15  per  cent, 
of  cases  does  the  blood  come  from  the  ruptured  uterine  vessels.  It  is 
a  very  erroneous  idea,  therefore,  but  one  generally  expressed  by  those 
with  little  experience  of  this  complication,  that  rupture  of  the  uterus 
is  followed  immediately  by  profuse  bleeding.  Infinitely  more  common 
is  a  slow  but  steady  haemorrhage.  The  pulse-rate  in  such  cases 
slowly  rises,  and  uneasiness  and  general  abdominal  pain  and  the 
ordinary  symptoms  of  collapse  become  gradually  more  pronounced. 
The  case  already  recorded  is  an  illustration  of  this,  as  was  also  one 

i  Brit.  Med.  Journ.,  August  24,  1907. 

2  Arch.f.  Gyn.,  1905,  Bd.  lxxvi..  Heft  3,  p.  601. 


EUPTUEE  OF  THE  UTEEUS  637 

brought  to  me  from  the  country  some  years  ago.  This  patient, 
although  driven  some  eight  miles,  had  absolutely  no  symptoms  of 
collapse,  and  her  pulse  was  not  more  than  80.  She  was  found  to 
have  a  complete  rupture  of  her  uterus.  I  removed  the  uterus,  and  she 
made  a  most  satisfactory  recovery. 

When  all  the  classical  symptoms  are  present,  there  is  very  little 
difficulty  in  coming  to  a  diagnosis.  There  are  few  other  conditions 
associated  with  similar  symptoms.  Accidental  hemorrhage  and 
placenta  previa  are  undoubtedly  attended  with  all  the  symptoms  of 
collapse  and  hemorrhage,  but  a  vaginal  examination,  at  least  in 
the  case  of  placenta  previa,  reveals  the  condition.  With  accidental 
hemorrhage,  either  apparent  or  concealed,  it  occasionally  happens 
that  the  diagnosis  is  rendered  difficult,  and  scattered  through  obstetric 
literature  are  several  recorded  cases  of  mistaken  diagnosis.  In  such 
cases  the  history  and  the  presence  or  absence  of  tenseness  and 
tenderness  of  the  uterus  will  usually  clear  matters  up.  Besides,  in 
most  cases  of  uterine  rupture  one  can  feel  the  tear. 

The  diagnosis  between  complete  and  incomplete  rupture  can  only 
be  arrived  at  by  a  vaginal  examination,  except  in  the  cases  where  the 
child  is  evidently  free  in  the  peritoneal  cavity.  When  the  rupture  is 
complete,  one  feels  the  intestines  distinctly ;  when  it  is  incomplete,  that 
is  not  possible.  In  theory,  that  is  simple  enough,  but  once  or  twice  I 
have  had  a  little  difficulty  in  deciding,  for  the  peritoneum  is  very 
thin. 

Prognosis. 

The  prognosis  of  rupture  of  the  uterus  is  much  more  favourable 
to-day  than  it  was  when  the  condition  was  treated  expectantly.  When 
the  latter  treatment  was  in  vogue  many  cases  were,  of  course,  never 
appreciated.  But  even  amongst  those  which  were  recognized  occa- 
sional recoveries  followed.  A  former  physician  of  the  Maternity 
Hospital  told  me  of  one  in  which  after  delivery  of  the  child  he  had 
pushed  his  hand  through  an  extensive  and  complete  rupture,  and 
had  easily  felt  the  bowels.  The  patient  made  an  uninterrupted 
recovery  without  an}T  treatment.  Scattered  through  obstetric  litera- 
ture are  many  extraordinary  cases,  but  certainly  amongst  the  most 
wonderful  is  one  recorded  by  Leopold,1  in  which  rupture  occurred 
at  the  fourth  month,  and  yet  pregnancy  continued  to  term,  when  the 
child  died.  On  opening  the  abdomen  three  months  later  the  child 
was  removed.  Its  umbilical  cord  was  found  to  run  through  an  open- 
ing in  the  posterior  wall  of  the  uterus.  But  it  is  profitless  to  consider 
such  rarities. 

1  Arcluvf.  Gyn.,  1896,  Bd.  Hi.,  p.  376. 


688  Ol'KKATIYE   MIDWIFERY 

Various  estimates  have  been  given  of  the  mortality  from  the  ex- 
pectant treatment,  hut  it  appears  to  have  been  90  per  cent,  at  l< 
amongst  recognized  cases  of  complete  rupture.    Naturally,  it  was  much 
lower  in  the  incomplete  variety. 

In  recent  years,  with  a  more  exact  understanding  of  the  condition 
and  with  the  adoption  of  active  treatment,  the  mortality  has  fallen 
fully  a  third.  It  is  still,  however,  50  to  GO  per  cent.,  being  a  little 
higher  than  that  figure  for  complete,  and  a  little  lower  for  incomplete, 
rupture.  This  question,  however,  will  be  more  carefully  considered 
when  the  different  methods  of  treatment  are  being  discussed. 


Treatment. 

As  rupture  of  the  uterus  is  so  often  a  preventable  accident,  it  is 
necessary  that  I  should  say  a  word  or  two  about  its  prophylaxis.  As 
regards  those  cases  where  the  uterus  has  been  previously  injured, 
either  by  tears,  incisions,  curettage,  or  disease,  subsequent  pregnancies 
should  be  watched,  and  especially  should  the  patient  be  under  careful 
observation  during  the  later  weeks,  so  that,  should  rupture  occur,  an 
operation  could  be  immediately  undertaken.  The  same  applies  to 
cases  in  which  previous  labours  have  been  difficult  and  protracted, 
owing  to  malformations  of  the  pelvis,  or  undue  size  of  the  children  ; 
for,  as  we  have  seen,  previous  lacerations  are  often  passed  unrecog- 
nized, and  a  lower  segment  which  has  once  been  overstretched  yields 
and  tears  more  readily. 

As  the  danger  of  rupture  during  the  first  stage  is  practically  nil, 
excepting  in  cases  where  there  have  been  previous  lacerations  or 
injuries  to  the  uterus,  there  is  nothing  to  be  done. 

In  the  second  stage,  however,  if  any  of  the  premonitory  symptoms 
of  rupture  arise,  delivery  must  be  carefully  completed.  In  contracted 
pelvis  the  degree  of  deformity  and  the  relative  size  of  fcetal  head 
and  pelvis  must  be  carefully  calculated,  and  the  safest  treatment 
adopted.  As  rupture  of  the  uterus  occurs  so  commonly  in 
neglected  transverse  presentations,  it  is  of  the  greatest  importance 
that  such  a  malposition  of  the  child  should  be  early  recognized  and 
corrected.  Again,  if,  for  any  reason,  the  presentation  has  not  been 
appreciated,  or  the  accoucheur  has  not  seen  the  case  until  after  labour 
is  far  advanced,  attempts  at  version  must  on  no  account  be  made, 
unless  there  is  every  prospect  of  the  child  being  easily  turned. 
The  treatment  of  cases  of  impacted  transverse  presentation  has 
been  already  discussed  (Chapter  VI.).  I  would  commend  to  my 
readers  the  remarks  there  made.     The  disastrous  results  that  follow 


RUPTUBE  OF  THE  UTEBI  S  639 

attempts  at  version    in   such   cases  are    greatly  to    the    discredit  of 
the  obstetric  art. 

Hydrocephalus,  another  condition,  as  we  have  seen,  occasionally 
followed  by  rupture,  is  much  more  difficult  to  recognize,  especially  if 
the  child  presents  by  the  breech.  Its  diagnosis  and  treatment  have 
been  considered  elsewhere  (Chapter  YIL). 

Before  leaving  the  subject  of  prophylaxis  I  must  again  warn  the 
accoucheur  against  the  danger  of  performing  vaginal  operations,  such 
as  turning,  etc.,  with  the  woman  only  partly  anaesthetized.  Strong 
contractions  of  the  abdominal  and  pelvic  muscles  and  of  the  uterus 
are  set  up  by  the  introduction  of  the  hand,  and  in  consequence  many 
cases  of  rupture,  especially  of  rupture  of  the  vaginal  vault,  are 
brought  about  by  the  operator  requiring  to  employ  undue  force  in 
overcoming  the  resistance  of  the  tissues. 

Active  Treatment. — The  treatment  of  rupture  of  the  uterus  is 
a  subject  regarding  which  there  are  still  considerable  differences  of 
opinion,  and  in  all  probability  it  will  continue  in  this  position  for 
some  time  to  come. 

Before,  however,  the  active  treatment  of  rupture  can  be  discussed, 
we  must  consider  what  is  to  be  done  with  the  child  if  it  is  still 
undelivered  when  the  rupture  is  recognized.  In  certain  cases  this  is 
easy  to  decide,  in  others  it  is  difficult.  If  the  head  is  presenting  and 
can  easily  be  reached,  it  should  be  extracted  with  forceps.  Often  it 
will  be  necessary  to  perforate  it,  for  in  many  such  cases  the  pelvis  is 
deformed,  the  head  is  of  unusual  size  or  in  an  unfavourable  position, 
and  the  child  is  dead  or  dying.  Similarly,  if  the  breech  is  accessible 
and  one  or  both  legs  can  be  seized,  the  child  should  be  extracted  by 
traction,  and  if  there  is  any  difficulty  with  the  after-coming  head  it 
should  be  perforated. 

Another  group  of  cases  in  which  the  course  of  treatment  is  obvious 
are  those  in  which  the  child  has  entirely  escaped  into  the  abdominal 
cavity.  In  such  cases  the  uterus  has  retracted,  and  extraction  per 
raginam  is  evidently  impossible  ;  consequently  the  foetus  must  be 
removed  by  abdominal  section. 

The  cases  which  present  the  greatest  difficulty  are  those  where  the 
child  has  partly  escaped  through  the  rent.  In  many  of  these  the 
presentation  was  originally  transverse,  but  in  some  the  head  was 
the  presenting  part.  Whatever  the  presentation  was,  the  head  is  the 
part  which  is  generally  through  the  rupture.  In  such  cases  the 
course  to  be  pursued  will  depend  on  whether  one  intends  to  continue 
the  further  treatment  of  the  case  one's  self,  or  to  place  the  patient  in 
the  hands  of  another,  be  it  in  the  woman's  own  home,  a  hospital,  or 
a  nursing  home.     The  reason  for  this  is  obvious :  the  child  is  acting 


640  OPERATIVi:  MI  I  »\VI  l'KKY 

plug.  It  should  only  be  removed,  therefore,  when  the  operator 
is  ready  to  proceed  with  the  further  treatment.  Whoever  takes  chi 
of  the  further  care  of  the  patient  will  have  to  decide  between  removing 
the  child  per  vaginam  or  per  abdomen.  If  possible,  he  should  do  it 
per  vaginam,  because  if  he  drags  it  up  through  the  abdominal  wound 
he  will  carry  up  infection.  Usually  the  vaginal  delivery  will  be  best 
accomplished  by  bringing  down  one  or  both  feet ;  rarely  will  it  be 
possible  to  complete  it  by  craniotomy  or  decapitation  of  the  fore- 
coming  head.  The  abdominal  route  should  be  chosen  when  the 
child's  shoulders  are  beyond  the  tear. 

The  treatment  of  the  lacerated  uterus  after  the  child  has  been 
delivered  depends  largely  upon  the  variety  of  rupture.  In  cases  of 
incomplete  rupture,  plugging  the  tear  is  the  best  course.  There  are 
two  ways  of  plugging  the  tear — it  may  be  done  tightly  or  loosely. 
The  former  method  must  be  employed  if  the  bleeding  is  at  all  severe, 
but  the  latter,  especially  if  a  drainage-tube  is  inserted  along  with  the 
gauze,  gives  better  drainage.  It  is  not  necessary  to  douche  out  the 
tear  before  plugging.  The  gauze  should  be  inserted  with  the  cervix 
steadied  by  means  of  vulsellum  forceps,  and  should  not  be  removed 
until  forty-eight  hours  have  elapsed. 

In  cases  of  incomplete  rupture,  in  which  the  abdomen  is  opened 
under  the  suspicion  that  the  rupture  is  complete,  it  is  usually  advisable 
to  leave  the  uterus,  plug  the  cervix  from  the  vagina,  and  then  close 
the  abdomen. 

A  very  pertinent  question  in  connexion  with  this  method  of 
dealing  with  a  ruptured  uterus  is  the  subsequent  treatment  of  the 
organ,  for  the  danger  of  rupture  at  a  succeeding  pregnancy  is  con- 
siderable, as  recorded  cases  show.  A  ragged  tear  treated  by  plugging 
must  always  be  followed  by  a  cicatrix,  which  is  liable  to  give  way  in 
a  succeeding  pregnancy,  and  not  only  in  the  later  weeks,  but  even 
as  early  as  the  fourth  or  fifth  months.  Probably  the  safest  course 
to  pursue  in  such  cases  is  to  remove  the  uterus  some  time  after  the 
patient  has  recovered  from  the  accident.  If  the  accoucheur  deems  it 
safe  enough  to  permit  another  pregnancy,  he  must  make  sure  that 
the  patient  is  kept  under  observation  during  the  later  weeks,  in  case 
the  old  tear  gives  way. 

With  the  great  improvement  in  technique  and  the  results  of 
abdominal  surgery,  it  is  not  surprising  that  good  results  were 
expected  from  opening  the  abdomen  and  removing  the  uterus  or 
stitching  the  tear.  But  I  fancy  most  of  us  who  have  adopted  such  a 
course  have  been  a  little  disappointed  with  the  results,  for  the  mortality 
is  still  high,  because  of  the  collapsed  condition  of  the  patient  at  the 
time  of  operation  and  the  sepsis  that  so  frequently  follows.     Of  my 


EUPTUEE  OF  THE  UTEEUS  641 

fatal  cases,  two  died  of  shock  very  shortly  after  the  operation,  and 
four  of  sepsis.  One  is  not  disheartened  by  death  from  shock,  for  in 
this  condition  it  is  often  impossible  to  prevent  it ;  but  it  is  very 
disappointing  when  a  patient  recovers  from  the  shock  and  dies  of 
septicaemia.  In  the  cases  which  died  of  sepsis  the  patients  died  on  the 
fourth,  fifth,  eleventh,  and  thirteenth  days  respectively.  It  is  not  to 
be  wondered  at  that  septicaemia  so  frequently  follows.  Many  of 
the  cases  have  been  carelessly  handled  ;  the  tissues  have  been  much 
bruised ;  micro-organisms  have  been  introduced,  and  actually  rubbed 
into  the  tissues  during  the  various  manipulations  carried  out ;  and 
the  patients  are  exhausted  by  prolonged  labour  and  loss  of  blood. 
Nothing  could  be  more  favourable  for  the  occurrence  of  infection. 

Table  of  Author's  Cases. 


Number  of  Cases.      Maternal  Deaths. 


Died  unoperated  upon  (complete)            ...          ...  o  3 

Plugging  (all  incomplete)  ...         ...         ...         ...  "> 

Hysterectomy  (Porro's)  (incomplete)      1  1 

, ,  retroperitoneal  treatment  of  stump 

(all  complete)       ...         ...         ...         ...         ...  5  3 

Panhysterectomy  (all  complete)  ...          5  2 


Total  maternal  mortality  in  cases  treated     ...         ...         ...     43  per  cent. 

Mortality  for  hysterectomy  (11  cases,  6  deaths)      ...         ...     54         „ 


When  the  abdomen  has  been  opened  for  the  purpose  of  extracting 
Che  child,  or  when  abdominal  section  is  decided  upon  after  the  child 
has  been  removed  by  the  vagina,  there  are  several  modes  of  dealing 
with  the  uterus. 

(a)  Complete  removal  of  the  organ — panhysterectomy. 

(b)  Supravaginal  amputation,  with  retroperitoneal  treatment  of  the 

stump. 

(c)  Amputation  of  the  uterus  after  Porro's  method. 

(d)  Stitching  the  laceration  and  plugging. 

Panhysterectomy  is  the  most  radical  treatment.  My  own  results 
show  a  mortality  of  40  per  cent. 

The  method  of  carrying  out  the  operation  is  detailed  elsewhere 
;p.  423).  It  is  the  operation  which  I  think  will  ultimately  give  the 
best  results.  The  only  treatment  which  I  think  may  come  into 
jompetition  with  it  is  simple  stitching  of  the  peritoneum  and  draining. 
[  shall  refer  to  this  treatment  later. 

41 


642  OPERATIVE  MIDWIFERY 

Panhysterectomy  is  the  soundest  treatment,  because  by  this 
method  one  removes  the  uterus  (body  and  cervix  I,  both  of  which  are 
infected.  If  the  eases  of  ruptured  uterus  which  die  of  sepsis  are 
examined,  it  will  be  found  that  the  sepsis  is  generally  local.  That 
being  so,  the  best  thing  to  do  is  not  only  to  remove  the  entire 
uterus,  but  to  pack  the  pelvis  with  iodoform  gauze,  bring  the  end  out 
through  the  vagina,  and  leave  the  gauze  in  for  three  to  four  days.  In 
the  last  two  cases  I  have  employed  a  rubber  drainage-tube  surrounded 
with  gauze. 

The  operation  which  is  favoured  by  many  when  hysterectomy  is 
performed  is  supravaginal  amputation  of  the  uterus,  with  retro- 
peritoneal treatment  of  the  stump.  In  other  words,  the  peritoneum 
is  stitched  over  the  stump.  The  steps  of  the  operation  have  been 
already  fully  described.  The  advantages  claimed  for  this  method  are 
that  it  is  easier  than  total  hysterectomy,  takes  less  time,  and  so  is 
attended  with  less  shock.  I  think  these  advantages  are  theoretical, 
and  I  feel  sure  are  more  than  counterbalanced  by  the  ill-effects  which 
result  from  leaving  the  ragged  infected  stump  of  the  cervix  behind. 

My  own  personal  experience  from  this  method  has  not  been 
very  fortunate.  I  have  adopted  it  five  times,  but  have  only 
had  two  successes — a  mortality  of  GO  per  cent.  One  died  of  shock 
a  few  hours  after  the  operation,  and  the  others  of  sepsis  on 
the  fourth  and  eleventh  days  respectively.  This  is  the  great 
danger.  In  reading  over  the  recorded  cases  it  appears  that  the 
best  results  are  obtained  by  simply  bringing  the  peritoneum  over 
the  stump,  not  carefully  stitching  the  latter.  The  late  Milne  Murray1 
specially  referred  to  this  in  a  case  he  recorded  shortly  before  his 
death.  In  addition  to  giving  good  drainage,  it  saves  time,  so  that  the 
operation  can  easily  be  carried  out  in  twenty  minutes.  The  cellular 
tissue  should  also  be  drained  by  gauze  loosely  packed  round  a  rubber 
drainage-tube. 

Formerly  the  removal  of  the  uterus  and  the  treatment  of  the 
stump  after  Porro's  method  was  most  favoured,  but  in  recent  years  it 
has  almost  been  given  up,  so  that  in  cases  collected  from  the 
literature  1903- 1005  I  found  only  ten  reported,  with  50  per  cent, 
mortality.  Porro's  method  is  a  very  crude  method  of  treating  the 
stump.  Spencer,  Fehling,  and  a  few  others,  advocate  its  employment 
in  certain  cases  of  Cesarean  section  where  the  uterine  cavity  is 
infected ;  but  its  employment  in  rupture  of  the  uterus  is  of  no 
advantage,  for  the  cervix,  the  vaginal  vault,  and  the  cellular  tissue 
are  infected. 

It  is  possible  that  the  last  method,  stitching  the  peritoneum,  may 

1  Trans.  Edin.  Obst.  Soc,  vol.  xxvii.,  p.  39. 


RUPTURE  OF  THE  UTERUS  G43 

come  into  favour,  as  it  has  been  recently  advocated  by  no  less  an 
authority  than  Zweifel,  whose  results  from  hysterectomy  have  been  so 
insatisfactory.1  He  advocates  a  very  careful  abdominal  toilet,  stitch- 
ing the  peritoneal  coat,  but  is  opposed  to  draining  from  the  vagina. 
The  method  has  this  great  advantage,  that  it  can  be  easily  performed 
ind  may  be  carried  out  in  the  patient's  own  dwelling,  as  witness  a  most 
interesting  case  recently  recorded  by  Down,2  who  not  only  saved  the 
mother,  but  saved  the  child. 

It  is  a  mistake,  however,  not  to  drain,  for  there  must  be  some 
infected  material  left  in  the  peritoneum.  Eversmann's  figures 
indicate  that  the  results  are  better  when  drainage  is  employed. 

It  is  very  questionable  if  stitching  the  whole  thickness  of  the  torn 
3dges  of  the  wound  is  advisable,  for  it  is  not  sound  surgery  to  stitch 
i  lacerated  infected  wound  (in  Zweifel's  recent  recommendation  of 
stitching  it  is  only  the  peritoneum  that  is  stitched). 

Plugging  and  draining  the  tear,  even  although  the  laceration  is 
complete,  is  favoured  by  several  operators,  and  in  this  country  has 
i  strong  advocate  in  Spencer.  It  certainly  gives  surprisingly  good 
•esults.  In  one  respect  this  is  highly  satisfactory,  for  it  is  the 
simplest  treatment  for  the  practitioner  who  has  no  experience  of 
abdominal  surgery.  Naturally  in  all  cases  where  this  conservative 
nethod  is  employed  the  accoucheur  must  make  sure  that  all  bleeding 
s  arrested. 

Laceration  of  the  Cervix. 

Slight  laceration  of  the  cervix  is  unavoidable  in  a  primipara 
lelivered  at  term  of  a  normal-sized  child.  In  most  cases  the  lacera- 
ion  is  slight,  and  in  some  can  hardly  be  appreciated. 

The  laceration  most  commonly  occurs  on  the  left  side  of  the 
ervix.  The  explanations  generally  given  for  this  are,  that  the 
.terus  being  usually  displaced  to  the  right,  there  is  a  greater  strain  on 
he  left  side  of  the  cervix,  and  that  in  so  many  cases  the  head  comes 
hrough  the  cervix  with  the  occiput  directed  towards  the  left  side. 
Intil  recent  years  I  was  of  opinion  that  extensive  lacerations  of  the 
ervix  only  occurred  in  cases  that  were  interfered  with,  either  by 
ragging  the  child  through  the  undilated  cervix  or  by  administering 
rgot.  I  have,  however,  seen  cases,  in  both  my  hospital  and  private 
ractice,  in  which  extensive  lacerations  occurred  where  labour  was 
pontaneous  ;  nor  is  this  to  be  wondered  at,  for  the  forces  and  resist- 
nce  of  the  parts  are  seldom  absolutely  normal.     But  although  the 

1  Hegar's  Beitrage,  Bd.  vii.,  p.  1. 
-  Lancet,  1904,  vol.  ii.,  p.  755. 


en 


OPERATIVE  MII>U  II1.1;V 


obstetrician  cannot  be  blamed  for  extensive  lacerations  of  the  cervix 
in  all  cases,  it  must  be  admitted  that  in  the  va.-t  majority  of  cases  the 
tearing  results  from  too  early  extraction  of  the  child  with  forceps,  or 
dragging  on  the  breech.  It  is  highly  undesirable,  therefore,  unless 
thf  life  of  the  mother  or  child  is  in  great  danger,  to  forcibly  drag  the 


Fig.  284. — Stitches  applied  in  Suturing  a  Lacerated  Cervix. 

child  through  an  incompletely  dilated  os.  In  considering  forcible 
dilatation  of  the  cervix  and  the  methods  for  carrying  out  this  opera- 
tion, I  referred  to  the  dangers  of  lacerating  the  cervix,  particularly  in 
cases  where  the  cervix  was  unobliterated  and  the  pregnancy  was  still 
of  an  early  date.  Details  regarding  the  prevention  of  cervical  injury 
in  such  cases  will  be  found  in  Chapter  XXVIII. 


LACERATION  OF  THE  CERVIX  645 

In  but  few  cases  does  laceration  of  the  cervix  manifest  itself  by 
iny  particular  signs  or  symptoms.  True,  in  certain  cases  there  is 
haemorrhage  of  a  more  or  less  profuse  character,  which,  as  I  said 
jefore,  was  to  be  distinguished  from  haemorrhage  from  the  placental 
site  by  the  fact  that  the  uterus  was  well  contracted,  but  in  not  a  few 
3ases  the  haemorrhage  is  slight. 

It  is  undesirable  to  introduce  the  fingers  into  the  parturient  canal 
unless,  after  a  difficult  accouchement,  there  is  the  probability  that  the 
cervix  is  injured  ;  it  is  undesirable  to  search  for  any  laceration ;  when, 
however,  it  is  suspected,  either  from  the  haemorrhage  or  by  reason  of 
the  operative  interference,  it  is  well  to  examine  the  cervix.  This  is 
best  done  by  attaching  vulsellum  forceps  to  the  anterior  and  posterior 
lips  and  pulling  the  cervix  down.  In  doing  this  it  must  not  be 
forgotten  that  the  tissue  is  very  friable  and  easily  torn,  so  too  great 
traction  must  not  be  applied  with  the  forceps.  The  uterus  should 
also  be  pressed  down  from  above. 

Should  a  tear  in  the  cervix  be  discovered,  it  must  be  carefully 
stitched  with  catgut,  and  as  far  as  possible  the  whole  thickness  of  the 
cervical  wall  embraced  in  the  ligature.  The  illustration  shows  how 
the  stitches  are  introduced  (Fig.  284).  It  will  often  be  found  best  to 
introduce  the  lowermost  one  first,  and,  using  it  as  a  tractor  on  the 
cervix,  insert  the  others.  For  stitching  the  cervix  a  medium-sized 
half-circle  needle  is  the  best  one  to  employ  ;  also  it  will  be  found  that 
a  needle-holder  is  of  distinct  advantage.  When  the  sutures  are 
inserted  they  should  be  tied  and  cut  short. 

Laceration  of  the  Perineum. 

In  ordinary  obstetric  practice  this  is,  in  all  probability,  the 
commonest  accident  that  occurs.  Left  to  nature,  lacerations  of  the 
perineum,  more  or  less  extensive,  frequently  occur — indeed,  they  are 
the  rule.  I  have  always  carefully  examined  the  perineum  after 
delivery  in  cases  of  primiparoe,  where  the  birth  occurred  spontaneously 
without  any  attention  from  nurse  or  doctor,  and  I  have  usually  found 
lacerations.  Undoubtedly,  in  certain  cases  the  perineum  has  entirely 
escaped,  but  that,  in  my  experience,  is  the  exception ;  indeed,  in  some 
cases  I  have  seen  very  extensive  laceration  of  the  perineum  result. 
On  the  other  hand,  in  most  cases  conducted  by  an  accoucheur  of 
experience  only  slight  tears  are  the  rule,  and,  indeed,  in  a  great 
number  of  cases  practically  no  tearing  at  all  results  ;  there  is  a  slight 
tear  of  the  fourchette,  but  that  is  all.  From  these  two  facts  it  is 
evident  that  a  very  great  deal  can  be  done  by  the  intelligent  and 
practised  obstetrician  in  preventing  lacerations  of  the  perineum   and 


646  OPERATIVE   MlhW  1FK1;Y 

it  is  most  important  that  the  young  obstetrician  should  give  this 
matter  his  most  careful  consideration  and  attention.  He  will  require 
to  attend  a  large  number  of  deliveries  before  he  gains  the  requisite 
amount  of  skill  and  dexterity  in  guiding  the  head  safely  over  the 
perineum. 

I  need  not  impress  upon  my  readers  the  importance  of  preserving 
the  perineum,  and  should  it  rupture,  as  rupture  it  will  in  certain 
cases,  of  repairing  it  carefully.  The  future  comfort  of  the  woman 
depends  in  great  part  on  the  preservation  of  this  all-important  pelvic 
support.  Every  one  is  familiar  with  the  chronic  catarrhs,  displace- 
ments, dragging  pains,  etc.,  complained  of  by  women  where  the 
perineum  has  been  destroyed  and  has  not  been  carefully  repaired. 

Many  conditions  favour  laceration  of  the  perineum.  Amongst 
these  may  be  mentioned  a  large  head,  and  especially  a  much  ossified 
head  incompletely  moulded ;  unfavourable  presentations  of  the  head, 
especially  occipito-posterior  presentations ;  rapid  extraction  of  the 
unmoulded  after-coming  head  ;  and  large  shoulders.  On  the  side  of 
the  mother,  we  have  a  narrow  pelvic  outlet,  which  necessitates  especial 
distension  of  the  perineum  before  the  head  can  round  the  symphysis. 
One  very  frequently  hears  the  accoucheur  blame  the  consistency  of 
the  perineum  for  the  laceration,  and  although  he  is  often  simply 
excusing  himself,  in  not  a  few  cases  he  is  justified  in  his  contention, 
because  the  tissues  are  sometimes  so  soft  that  the}7  tear  on  the 
slightest  distension,  or  so  rigid  that  they  refuse  to  distend.  In  the 
former  condition  of  the  perineum  nothing  can  be  done  to  prevent 
laceration  ;  all  that  one  can  aim  at  is  to  control  the  tear  as  far  as 
possible.  In  the  latter  condition,  however,  laceration  of  any  extent 
may  be  prevented  by  the  administration  of  opium  or  chloroform, 
which  relaxes  the  part  sufficiently  to  permit  of  a  more  complete  dis- 
tension. In  these  cases,  when  the  perineum  is  rigid,  fomenting  the 
perineum  or  smearing  it  with  a  lubricant  has  been  recommended  : 
neither  of  these  devices  is  of  any  value. 

Apart  from  these  conditions  referred  to,  laceration  of  the  perineum 
not  infrequently  occurs  through  a  faulty  manual  or  instrumental 
delivery.  In  difficult  deliveries  the  accoucheur,  in  his  anxiety  to 
extract  the  child,  tears  the  perineum  with  his  hand  or  with  the 
instrument.  I  have  riot  infrequently  seen  cases  in  consultation  or 
brought  into  hospital  where  the  perineum  has  been  destroyed  before 
the  head  has  been  brought  down  to  the  pelvic  Moor.  Lacerations  of 
this  nature  should  not  occur  if  the  operator  is  careful  and  does 
not  excitedly  carry  out  his  manipulations. 

In  ordinary  cases  there  are  three  points  to  attend  to  in  preserving 
the  perineum  :  (a)  The  presenting  part  should  be  allowed  to  distend 


LACERATION  OF  THE  PERINEUM 


'117 


he  perineum  when  that  is  at  all  possible  ;  (/>)  the  head  should  be 
maintained  in  an  attidude  of  flexion  when  it  is  delivered ;  (c)  the 
head  should  be  allowed  to  escape  slowly  through  the  vulvar  orifice. 

It  is  most  desirable,  when  at  all  possible,  to  allow  the  perineum  to 
become  slowly  stretched  by  the  presenting  part.  Of  course,  in  certain 
cases,  where  the  life  of  the  child  or  the  mother  is  in  danger,  this 
cannot  be  permitted  ;  but  these  cases  are  fewer  than  is  generally 
supposed,  and  if  a  little  more  patience  were  exercised  by  the  medical 
attendant,  they  would  become  much  less  frequent.  When  it  is 
necessary  to  drag  a  child  from  the  pelvic  cavity,  this  should  be  done 
slowly  and  cautiously,  so  as  to  permit  of  gradual  stretching  of  the 


Fig.  285. — The  Prevention  of  Perineal  Laceration. 
The  accoucheur  is  controlling  the  passage  of  the  head  through  the  vulvar  orifice. 


pelvic  floor.  An  anaesthetic  should  always  be  employed  in  order  that 
the  parts  may  be  as  relaxed  as  possible. 

Next  to  allowing  the  perineum  to  be  distended,  it  is  of  the  greatest 
importance  that  the  head  should  escape  flexed.  In  that  attitude  the 
smallest  circumference  of  the  head — the  suboccipito-bregmatic  — 
passes  through  the  vulvar  orifice. 

Lastly,  the  head  must  be  allowed  to  escape  slowly  so  that  the 
vaginal  outlet  is  gradually  distended. 

There  are  many  methods  described  for  guiding  the  head  over  the 
perineum,  but  the  differences  in  detail  are  of  comparatively  little 
moment,  provided  the  three  important  points  already  mentioned  are 
attended  to.  I  will,  therefore,  only  describe  the  method  which  I 
have  found  the  best,  and  which  is  employed  in  the  Glasgow  Maternity 
Hospital.     When   the   head   appears   through  the  vulvar  orifice,  its 


648 


OPERATIVE  MIDWIFERY 


progress  is  very  carefully  watched,  and  the  patient  and  accoucheur 
lake  up  positions  as  indicated  in  the  illustration  (Fig.  285).  The  patient, 
lying  in  the  left  lateral  position  (I  helieve  one  has  better  control  over 
the  patient  in  tbie  than  in  the  dorsal  decubitus),  is  placed  across  the 
I  •<!,  with  her  pelvis  slightly  over  the  edge  of  the  bed.  The  accoucheur 
stands  with  his  back  to  the  patient.  His  left  arm  is  passed  between 
the  patient's  thighs,  and  the  palm  of  the  hand  is  placed  over  the 
occiput  as  the  head  is  driven  down  with  each  pain.  The  palm  of  the 
hand  controls  the  escape  of  the  head ;  but  it  is  also  employed  from 
time  to  time  in  preventing  the  occiput  hitching  against  the  symphysis 
pubis   and   becoming  extended   (Fig.  286).     It  will  be  seen  also   in 


Fig.  286. — The  Prevention  of  Perineal  Laceration. 

The  accoucheur  is  maintaining  flexion  of  the  head  and  preventing  the  occiput  from 
catching  against  the  symphysis  pubis. 

the  illustration  that  the  fingers  of  this  hand  take  pressure  off  the 
posterior  commissure  of  the  vaginal  orifice.  The  other  hand  at  first 
does  nothing  except  assist  the  right  hand  in  preventing  the  too  rapid 
escape  of  the  head  should  the  pains  be  unduly  severe.  With  each 
succeeding  pain  a  little  more  of  the  child's  head  is  allowed  to  escape. 
The  final  delivery  of  the  head  should  be  completed  in  the  interval 
between  two  pains,  and  it  is  a  great  advantage  to  have  the  patient  at 
this  stage  deeply  anaesthetized.  The  actual  delivery  is  carried  out  by 
pushing  the  head  through  the  vulvar  orifice,  with  the  right  hand 
pressing  upon  the  forehead  from  behind  the  anus  (Fig.  287).  The 
great  mistake  is  in  commencing  this  pushing  out  of  the  head  too  soon, 
for  if  that  is  done  the  head  is  extended.  Unless  there  is  some  reason 
for  unduly  hastening  the  delivery,  the  anterior  margin  of  the  anterior 


LACERATION  OF  THE  PERINEUM 


649 


fontanelle  should  have  reached  the  posterior  commissure  before  this 
manoeuvre  is  employed.  One  is  often  disappointed  by  seeing  a 
laceration  occur  just  at  the  last  moment  when  the  forehead  is 
escaping,  especially  if  the  head  is  imperfectly  moulded. 

The  method  described  and  the  position  taken  by  the  accoucheur 
is,  I  believe,  the  best,  for  if  one  attempts  to  control  the  delivery 
without  having  an  arm  round  the  thigh  of  the  patient  one  has  not 
the  same  command  over  her.  She  may  suddenly  make  a  movement 
at  the  height  of  a  pain,  and  the  head  may  slip  from  one's  grasp. 

It  will  be  found  frequently  that  the  shoulders  increase  the  perineal 
tear  if  they  are  not  carefully  guided  over  the  perineum.     They  seldom 


Fig.  287.— The  Prevention  of  Perineal  Laceration. 

The  accoucheur,  while  maintaining  the  head  in  a  condition  of  flexion,  is  now  allowing  it  to 
escape  from  the  vulvar  orifice  during  the  intervals  between  the  pains. 

originate  tears,  but  the  point  of  the  shoulder  gets  into  the  laceration 
already  made  and  extends  it. 

At  this  point  it  may  be  well  to  say  a  word  regarding  the  making 
of  lateral  incisions  in  the  vaginal  orifice,  with  a  view  to  preventing 
lacerations  of  the  perineum.  The  technical  name  of  this  operation  is 
"  episiotomy."  On  theoretical  grounds  there  is  much  to  be  said  in  its 
favour,  for  by  having  recourse  to  it  one  often  preserves  the  perineum 
from  laceration,  and  it  is  much  simpler  to  stitch  up  exactly  a  clean 
incised  wound  in  the  lateral  wall  than  a  ragged  one  in  the  posterior. 
It  is  an  operation,  however,  that  is  only  rarely  required,  provided  the 
accoucheur  is  careful  and  attends  to  the  points  already  referred  to  in 
the  management  of  the  perineum.  It  is  difficult  to  decide  in  what 
cases  one  should  employ  the  operation,  for  on  the  one  hand,  if  one 
has  recourse  to  it  too  often  it  will  be  frequently  performed  unneces- 


650 


OPERATIVE  MIDWIFERY 


sarily.  while  on  the  other  hand,  if  one  delays  too  long,  any  advantage 
to  be  gained  in  performing  it  will  be  lost.  For  my  own  personal 
guidance  I  have  made  this  simple  rule— I  incise  the  lateral  wall  if  the 
posterior  commissure  of  the  vagina  tears  before  the  head  has  escaped 
to  any  extent.  The  incision  is  best  made  with  scissors  in  the  manner 
seen  in  the  illustration  (Fig.  288);  afterwards  the  wound  is  carefully 
stitched  with  silkworm  gut. 

The   Repair    of    Perineal   Lacerations.— In   spite  of  all   one's 
efforts  to  prevent  them,  perineal  lacerations  will  occasionally  occur. 


X 


/ 


Fig.  288. — Episiotomy.     (Hunan.) 


They  are  frequently  described  as  being  of  three  degrees  :  the  first, 
when  the  laceration  is  only  slight ;  the  second,  when  it  reaches  the 
margin  of  the  anus;  and  the  third,  when  it  extends  into  the  bowel. 

No  matter  how  small  the  perineal  tear  may  be,  it  should  be 
carefully  stitched,  for  it  is  important  not  only  to  preserve  the  floor  of 
the  perineum,  but  to  preserve  the  sphincter  of  the  vagina.  Besides, 
any  raw  surfaces  left,  especially  about  the  perineum,  are  open 
channels  for  infective  organisms  to  gain  an  entrance. 


LACEEATION  OF  THE  PEEINEUM 


651 


For  very  slight  tears  through-and-through  catgut  sutures  are 
quite  sufficient.  With  the  more  extensive  lacerations,  however, 
more  careful  suturing  is  required,  even  although  the  laceration  is 
only  of  the  second  degree  and   the   sphincter   ani  is  not  involved. 


Fig.  289. — Repair  of  a  Slight  Perineal  Tear.     (After  LJumm.) 

Personally,  I  have  found  the  results  from  stitching  the  whole  tissue 
through  and  through  with  silkworm  gut  hardly  satisfactory,  for  the 
laceration  often  extends  up  the  posterior  vaginal  wall,  and  exact 
coaptation  of   the   edges  of   the  wound   cannot   be   obtained.      One 


652 


0PE1JAT1VK  MIDWIFKIlY 


secures  quite  satisfactory  skin  union,  but  not  complete  union  of  the 
torn  recto-vesical  fascia  and  levator  ani  muscles.  The  consequence 
of  this  is  that  the  thin  pelvic  floor  yields  as  time  goes  on,  and  is 
practically  no  support  to  the  pelvic  organs. 

In  these  cases,  therefore,  I  think  it  well  to  put  in  one  or  two 


Fig.  290. — Repair  of  a  Complete  Tear. 
(After  Bumm.) 

The  stitches  as  here  applied  are  knotted 
in  the  rectum.  This  is  the  better  method 
ol  stitching  a  complete  tear. 


Fig.  291. — Repair  of  a  Complete  Tear. 
(After  Bumm.) 

The  stitches  as  lure  applied  are  knotted 
on  the  vaginal  side  and  left  buried. 


vaginal  sutures  of  catgut,  with  the  object  of  1  (ringing  the  vaginal  edges 
of  the  wound  into  exact  apposition  (Fig.  289).  This,  I  think,  is 
better  than  inserting  a  continuous  suture  from  the  vaginal  side, 
although  others  prefer  the  latter  method.  "Whichever  method  is 
employed,  four  or  five  silkworm  gut  sutures  should  be  inserted  and 


LACERATION  OF  THE  PERINEUM 


653 


tied  externally.  As  the  cut  ends  of  these  sutures  sometimes  cause  a 
good  deal  of  discomfort,  it  is  a  very  good  plan  to  knot  the  ends 
of  each  suture  together.  The  only  objection  to  this  device  is  that 
blood-clot  and  lochial  discharge  get  entangled  in  the  loops.  How- 
ever, if  the  nurse  is  careful  in  sponging  the  parts  this  should  not 
occur,  and  the  additional  comfort  to  the  patient  and  the  ease  with 


Fig.  292. — Repair  of  a  Complete  Perineal  Laceration.     (After  Bumm.) 

The  wound  into  the  rectum  having  been  closed,  there  is  here  shown  the  further  steps  in 

repairing  the  rupture. 


which  the  stitches  can  be  withdrawn  afterwards  is  in  most  cases,  I 
have  found,  a  decided  gain. 

Should  the  sphincter  be  involved  and  the  laceration  extend  into 
the  rectum,  the  wound  must  be  stitched  as  shown  in  the  illustrations. 
First  of  all,  two  or  three  sutures  are  passed  through  from  the  bowel 
so  as  to  close  up  the  tear  in  the  latter,  then  one  or  two  buried  sutures 


654  OPERATIVE  MIDWIFERY 

are  inserted  in  the  deep  part  of  the  perineal  body  to  bring  the  vaginal 
torn  edges  together,  and,  last  of  all,  three  or  four  silkworm  stitches  are 
introduced  from  the  outside  in  tho  manner  described  for  an  incom- 
plete laceration.  In  the  illustrations  (Figs.  2!)0  and  291)  are  shown  the 
alternative  methods  of  inserting  the  stitches  in  the  bowel.  I  have 
tried  both  methods,  but  am  fully  convinced  that  it  is  better  to  employ 
the  one  shown  in  Fig.  21)0,  and  knot  the  sutures  in  the  bowel.  After 
suturing  the  bowel,  the  repair  of  the  perineum  is  completed  as  shown 
in  the  illustration  (Fig.  292). 

Rupture  of  the  Symphysis  Pubis. 

Never  to  my  knowledge  has  this  accident  occurred  in  any  of  my 
private  or  hospital  patients.  In  two  cases,  however,  after  severe 
parturitions,  the  patients  complained  of  great  pain  in  the  neighbour- 
hood of  the  symphysis  pubis.  I  was  satisfied  at  the  time  that  the 
joint  had  been  injured,  but  I  could  not  discover  any  separation  of 
the  bones  or  undue  mobility  of  the  joint. 

One  would  naturally  expect  that  the  accident  would  result  from 
a  difficult  instrumental  labour.  Strassmann,1  for  example,  has 
described  one  in  which  it  followed  the  employment  of  high  forceps. 
But  in  not  a  few  cases  the  delivery  has  been  spontaneous.  Mayer2 
has  described  such  a  case,  and  referred  to  others  of  a  similar  nature. 
Huxley3  recently  detailed  one  which  occurred  in  the  Outdoor 
Department  of  the  Glasgow  Maternity  Hospital.  In  Mayer's  case  the 
joint  became  infected,  and  as  there  is  usually  some  vaginal  lacera- 
tion, it  is  readily  understood  how  this  may  occur.  The  treatment  for 
the  condition  is  to  stitch  any  vaginal  laceration,  and  to  strap  the 
pelvis  and  apply  a  firm  binder.  Should  the  joint  become  infected,  it 
should  be  drained. 

1  Verhandlung  Bent.  Gesell.  f.  Gi/n.,  1907,  p.  726. 

2  Hegar>s  Beilrage,  1907,  Bd.  xi.,  p.  200. 

3  Journ.  Ob-st.  and  Gyn.  Brit.  Emjrire,  November,  1910. 


CHAPTER  XXXYI 

OCCIDENTS  TO   MOTHER— Continued  ;   INVERSION   OF   UTERUS- 
PULMONARY  EMBOLISM— SUBCUTANEOUS  EMPHYSEMA 

is  the  present  work  is  devoted  entirely  to  operative  midwifery,  I  do 
.lot  deem  it  suitable  to  consider  in  any  detail  the  complications  which 
:ollow  parturition.  I  feel,  however,  that  I  must  refer  to  three  which 
occasionally  manifest  themselves  immediately  after  labour.  These 
ihree  are  :  inversion  of  the  uterus,  pulmonary  embolism,  and  sub- 
cutaneous emphysema. 

Inversion  of  the  Uterus. 

We  are  here  only  concerned  with  this  accident  as  it  occurs 
mmediately  or  shortly  after  the  birth  of  the  child,  so-called  '  acute 
inversion.'  I  do  not  intend  considering  cases  of  chronic  inversion,  or 
chose  which  result  from  the  presence  of  tumours,  etc. 

The  frequency  of  this  condition  is  variously  stated.  -Jardine,  for 
;he  Glasgow  Maternity  Hospital,  found  that  it  occurred  three  times  in 
51,290  cases. 

Naturally,  there  are  different  degrees  of  inversion — from  the 
simplest,  where  there  is  only  a  depression  over  the  fundus,  to  the 
nost  extreme,  where  the  uterus  is  turned  inside  out  and  the  vaginal 
walls  are  also  everted  (Fig.  293). 

Etiology. — As  regards  the  etiology  of  the  condition  opinions 
liffer,  for  while  some  consider  that  a  localized  atony,  more  particu- 
arly  of  the  placental  site,  along  with  active  contractions  of  the  rest  of 
the  uterus,  is  all  that  is  necessary,  others  hold  that  the  accident  results 
from  pure  atony,  the  inversion  being  produced  by  pressure  from 
ibove,  by  the  hand,  or  by  the  contraction  of  the  abdominal  muscles, 
Di'  dragging  on  the  cord  from  below.  The  latter,  without  doubt,  in  a 
arge  proportion  of  cases,  seems  to  be  the  correct  explanation  of  the 
3ccurrence  ;  but  it  is  quite  conceivable  that  the  former  view  may  also 
be  correct,  for  once  an  indentation  has  occurred,  it  is  evident  that 
complete  inversion  may  be  produced  by  uterine  contractions  alone. 

655 


OPERATIVE  MIDWIFERY 


The  most  valuable  and  original  contributions  to  the  etiology  and 

treatment  of  this  condition  in  recent  years  are  those  made  by  Bar.1 
Bar  has  pointed  out  how  little  the  anterior  vaginal  and  uterine  walls 
are  supported,  and  how,  therefore,  they  fall  down  and  drag  the  rest  of 
the  uterus  after  them.  Apart  from  uterine  retraction,  the  chief  supports 
against  inversion  are  the  infundibulo-pelvic  ligaments  (Pig.  294). 

Although,  as  one  would  expect,  multipara'  are  more  liable  to  this 
complication  than  primipara  ,  still,  there  are  quite  a  number  of  the 


FlG.  293. — Complete  Inversion  ol'  Uterus  and  Vagina.     <  Buniiu.) 

latter  ;  in  my  series  of  collected  cases  the  proportion  of  primiparse  to 
multipara  is  as  9  to  12. 

"Without  attempting  to  make  an  exhaustive  table  of  the  recorded 
cases,  I  collected,  for  the  years  1903  to  1905  inclusive,  twenty-three 
cases  from  English  and  Continental  literature.  In  examining  them  it 
was  evident  that  the  occurrence  followed  pressure  from  above  or 
traction  from  below  in  the  majority  of  the  cases. 

In  looking  over  the  series  I  was  not  a  little  surprised  at  the  large 

1  Bull,  de  la  Soc.  d'Ubst.  de  Paris,  1901,  1902. 


INVERSION  OF  Till-:   UTERUS 


657 


roportion  of  cases  in  which  traction  on  the  cord  was  the  cause. 
Vith  few  exceptions,  in  these  cases  mid  wives  had  charge  oi  the 
atients.  Of  course  one  must  not  forget  that  in  recording  cases 
f  inversion  of  the  uterus,  the  tendency  is  for  the  practitioner  to 
scord  those  cases  in  which  he  has  not  been  to  blame,  still,  even 
llowing  for  that,  traction  on  the  cord  appears  to  be  a  very  im- 
ortant  cause  of  inversion,  a  much  more  important  cause  than  I 
upposed.  In  this  connexion  an  interesting  case  is  recorded  by 
fighton  and  Collins,1  where  the  inversion  followed  the  birth  of   a 


Fig.  294.— Partial  Inversion  of  Uterus.     (Bar.) 

lild  with  an  unusually  short  cord  ;  the  cord  was  wound  round  the 
eck  and  trunk  of  the  child  several  times.  Similar  cases  where  the 
3rd  was  actually  short,  or  short  by  reason  of  being  wound  round  the 
lild,  have  been  recorded  by  several  writers.  Then,  again,  inversion 
as  followed  a  precipitate  labour  in  which  the  child  has  been  born 
ith  the  woman  sitting  in  an  erect  posture,  the  child  in  its  fall 
ragging  on  the  cord. 

Next  in  frequency  to  dragging  on  the  cord  comes  increased 
xlominal  pressure,  such  as  is  produced  by  straining,  coughing, 
leezing.     In  two  cases,  those  reported  by  Pompe2  and  Falk,:i  the 


1  Journ.  Obstet.  and  Gyn.  Brit.  Empire,  October,  1905,  p.  250. 

2  Zent.f.  Gyn.,  1903,  p.  612.  3  Ibid.,  1904.  p.  1441. 


42 


OPERATIVE  MII'WII  i:i:v 

inversion  appears  to  have  been  produced  by  injudicious  employment 
o!  Cred6'fi  method  of  expressing  the  placenta.  On  more  than  one 
occasion  I  have  produced  daring  the  third  stage  slight  indentations 
by  pressing  upon  the  fundus  of  an  atonic  uterus,  in  such  cas 
if  pressure  had  been  continued,  without  doubt  complete  inversion 
could  easily  have  been  brought  about.  Credo's  method  of  express- 
ing the  placenta  should  never  be  employed  until  the  uterus  is  in  a 
state  of  contraction. 

It  has  occasionally  happened  that  inversion  has  followed  the 
manual  removal  of  a  placenta,  either  by  reason  of  the  external  hand 
pressing  firmly  upon  an  atonic  uterus,  or  the  internal  hand  being 
withdrawn  and  establishing  a  negative  pressure. 

Symptoms,  Diagnosis,  and  Prognosis. — As  a  rule,  the  symptoms 
of  this  accident  are  very  pronounced.  Generally  there  is  a  feeling  of 
something  coming  down,  quickly  followed  by  more  or  less  pronounced 
collapse  and  haemorrhage.  That  is  true,  at  least,  of  those  cases  where 
inversion  is  complete.  Where  it  is  only  of  a  slighter  degree,  and  the 
fundus  does  not  come  beyond  the  os  externum,  only  pain  and  hainor- 
rhage  may  be  present.  Very  seldom  indeed  are  symptoms  entirely 
absent,  but  Galabin  has  recorded  a  case  in  which  there  were  no 
symptoms  whatever,  either  immediately  after  the  delivery  or  during 
the  puerperium ;  the  condition  was  only  recognized  after  lactation 
had  ceased  and  when  irregular  hemorrhages  occurred.  Similar  cases 
have  been  described  by  several  other  writers.  Careful  vaginal  and 
bimanual  examination  will  at  once  reveal  the  nature  of  the  condition 
where  there  exists  a  complete  inversion,  for  a  large  body  will  be 
evident  projecting  from  the  vaginal  canal,  and  there  will  be  no  trace 
of  the  enlarged  uterus  above.  Sometimes  the  indentation  can  be 
made  out  from  the  abdomen. 

The  only  condition  that  simulates  inversion  of  the  uterus  is  a 
submucous  myoma  projecting  down  through  the  os,  but  in  such 
a  case  there  would  still  be  present  the  enlarged  uterus  above  the 
pubes.  Theoretically,  the  contractility  of  the  inverted  uterus  is  a 
diagnostic  feature  of  importance.  I  question,  however,  if  it  is  of  real 
value  in  practice.  Even  in  the  cases  where  there  is  only  slight 
inversion  a  careful  bimanual  examination  will  reveal  a  depression, 
and,  if  the  fingers  are  inserted  through  the  os  to  confirm  the  diagnosis, 
a  projecting  body  will  be  felt.  It  must  not  be  forgotten,  however, 
that  these  remarks  regarding  the  diagnosis  only  apply  to  acute 
inversion  ;  chronic  inversion  may  be  more  difficult  of  recognition. 

One  of   the  most   extraordinary  cases  of   mistaken  diagnosi-    is 
a  case  described  a  few  years  ago  by  Hickson  Smith,1  where  a  midwife 
1  Brit  Mel.  Journ.,  1S97,  vol.  i.,  p.  1476. 


INVERSION  OF  THE  UTERUS  659 

.hinking  she  had  to  deal  with  a  second  ehild,  pulled  upon  the  inverted 
items,  and  after  three-quarters  of  an  hour  succeeded  in  removing  it. 
vVhen  Dr.  Smith  arrived,  the  inverted  uterus  was  examined  by  him. 
Sven  more  extraordinary  is  the  fact  that  the  hemorrhage  was  slight, 
ind  that  the  patient  made  an  excellent  recovery.  The  treatment 
idopted  by  Dr.  Smith  was  simple  vaginal  plugging. 

Another  very  extraordinary  case  is  one  described  by  Henkel.1  In 
ihis  case  an  inverted  horn  of  a  double  uterus  (uterus  bicornis  unicollis) 
,vas  taken  first  for  an  inverted  uterus,  and  then,  because  a  uterine 
sound  passed  in  6  centimetres,  it  was  deemed  to  be  a  polypus.  The 
iumour  was  removed,  when  it  was  found  that  an  opening  had  been 
aiade  into  the  peritoneal  cavity,  proving  that  the  condition  was  an 
inverted  horn  of  a  double  uterus. 

Prognosis. — The  prognosis  for  inversion  of  the  uterus  is  very 
much  better  now  than  formerly,  for  it  is  less  likely  to  be  overlooked 
ind  sepsis  is  less  likely  to  follow.  Still,  the  number  of  fatal  cases  is 
not  inconsiderable.  Nor  is  this  to  be  wondered  at,  as  the  accident 
Dccurs  most  commonly  amongst  those  who  are  attended  b}T  midwives. 
[t  is  difficult  to  explain  some  of  the  deaths,  for  the  amount  of  blood 
^ost  is  not  sufficient  to  account  for  them.  The  shock,  however,  is 
}ften  very  considerable.  Of  the  twenty-three  collected  cases,  the 
omplication  proved  fatal  in  six  (28  per  cent.). 

Treatment. — Before  considering  the  treatment  of  inversion  when 
it  has  occurred,  let  me  say  a  word  regarding  prophylaxis.  On  no 
xccount  should  the  cord  be  dragged  upon  ;  on  no  account  should 
>ede's  method  be  injudiciously  employed ;  and  on  no  account  should  a 
ivoman  be  left  whose  uterus  is  not  firmly  retracted.  As  regards  the 
ast  point,  a  hot  intra-uterine  douche  and  ergot  will  generally  cause 
irm  retraction.  Personally,  I  am  entirely  opposed  to  the  employ- 
ment of  a  pad  underneath  the  binder,  as  was  very  commonly  the 
practice  in  this  country  until  recently,  for  should  the  uterus  become 
itonic  and  any  increased  abdominal  pressure  occur,  the  pad  will 
ictually  favour  the  occurrence  of  inversion. 

The  reduction  of  an  acutely  inverted  uterus  is  usually  accomplished 
without  much  difficulty.  In  my  twenty-three  collected  cases  it  is 
stated  to  have  failed  in  three,  and  to  have  been  accomplished  with 
difficulty  in  four.  It  is  commonly  recommended  to  replace  first  the 
part  that  became  last  inverted,  and  Bar  especially  recommends, 
in  difficult  cases,  attacking  the  anterior  part  first.  In  those  cases 
where  the  whole  uterus  is  relaxed  there  is  seldom  any  difficulty,  but 
where  Bandl's  ring  remains  firmly  contracted  an  incomplete  reduction 
— viz.,  the  removal  of  the  inverted  cervical  and  lower  uterine  segment 
1  Zent.f.  Gyn.,  1905,  p.  751. 


660  OPEEATIVE  MIDWIFERY 

— is  all  thai  can  be  accomplished.  It  is  very  important  to  remember 
that  it  is  generally  Bandi's  ring  thai  prevents  reduction,  not  the  c<  rvix, 
which  is  flaccid  after  delivery.  In  such  cases  the  employment  (if 
much  force  is  not  a  little  dangerous,  for  the  lower  segment  being 
so  thinned  out  and  non-resistant,  there  is  no  point  d'apjmi  :  the 
hand  must  be  applied  externally  in  order  to  supply  the  resistance 
necessary. 

Many  recommend  pushing  the  fingers  into  the  depression  through 
the  abdominal  wall  and  stretching  the  constriction.  They  claim  that 
they  have  succeeded  in  doing  this  ;  but  in  all  probability  they  have  not 
dilated  the  ring;  they  have  only  supplied  a  point  d'appui.  In  such 
cases,  undoubtedly,  deep  anaesthesia,  and  especially  chloroform  anaes- 
thesia, is  of  great  advantage,  and  although  I  cannot  speak  from 
personal  experience,  I  imagine  that  a  full  dose  of  morphia  would  be 
beneficial.  In  all  cases,  and  especially  when  chloroform  and  morphia 
have  been  freely  given,  there  is  a  distinct  danger  of  post-partum 
haemorrhage.  One  should  therefore  have  ready  to  hand  ergot,  a  hot 
douche,  and  packing,  in  case  haemorrhage  occurs. 

In  not  a  few  cases  the  placenta  has  remained  attached  to  the 
inverted  uterus,  and  in  such  it  is  generally  recommended  to  first 
attempt  replacement  with  this  body  attached,  as  it  is  a  certain  protec- 
tion to  the  uterus.  Should,  however,  replacement  be  impossible,  the 
placenta  and  membranes  must  be  carefully  stripped  off. 

As  regards  those  cases  where  reduction  entirely  fails,  various 
methods  of  treatment  have  been  advocated  :  the  most  radical  is 
abdominal  section  and  replacement  of  the  uterus  by  various  methods, 
such  as  Kustner's  and  others,  or  hysterectomy.  Very  few,  however, 
favour  such  procedures,  and  certainly  the  results  from  abdominal 
section  have  been  highly  unsatisfactory.  In  a  certain  number  of  cases 
where  reposition  has  failed,  a  spontaneous  rectification  has  occurred. 
Boxall1  records  a  most  interesting  case,  and  Spencer  and  Galabin,  in 
the  discussion  which  followed,  referred  to  similar  experiences.  In  fact, 
it  seems  to  be  quite  a  recognized  occasional  occurrence,  for  the  older 
writers  in  obstetrics  refer  to  it  also.  In  Boxall's  case  the  patient  had 
had  continuous  douches,  and  the  author  believed  '  that  the  constant 
douching  may  have  very  materially  assisted  the  process  of  reposition.' 
How  such  a  spontaneous  reposition  occurs  is  a  little  difficult  to 
explain,  but  if  one  reads  the  careful  description  of  the  anatomy  of 
this  complication  given  by  Bar,2  it  does  not  cause  one  so  much 
surprise.  We  all  know  how  frequently  a  retro  verted  gravid  uterua 
spontaneously  rights  itself,  and  so  it  is  no  wonder  that  occasionally 
the  inverted  uterus  should  do  the  same.  In  those  cases,  then,  where 
1  Trans.  Lond.  Obst.  Soc,  1904,  vol.  xlvi.,  p.  292.  2  0/>.  cit. 


INVERSION  OF  THE  UTERUS  661 

one  fails,  the  part  should  be  carefully  washed,  some  aseptic  gauze 
applied  round  the  organ,  douches  given  twice  daily,  and  subsequent 
attempts  made  at  replacement.  In  this  class  of  case  the  various 
repositors,  such  as  Aveling's,  which  are  so  useful  in  chronic  inversion, 
are  rather  difficult  to  apply  because  of  the  large  size  of  the  uterus. 
There  have  been  several  cases  of  successful  reduction  where  the  cup 
has  been  constructed  to  suit  the  size  of  the  uterus,  and  especially 
where  the  repositor  has  been  used  a  week  or  ten  days  after  the 
delivery.  Galabin1  refers  to  such  a  case.  The  various  metreurynters 
may  also  be  tried  ;  Pinard'2  mentions  several  successful  cases  where 
Champetier  de  Ribes'  bag  was  employed. 

By  adopting  the  conservative  treatment  just  sketched,  one  will 
without  doubt  succeed  in  getting  the  organ  replaced  in  almost  all 
cases,  and  even  should  one  fail  and  require  ultimately  to  have 
recourse  to  abdominal  section,  the  chances  of  a  successful  result  will 
be  much  greater  than  if  one  had  hurriedly  opened  the  abdomen 
because  in  the  first  attempts  reduction  failed. 

Recently  Tate3  described  a  most  interesting  case  where  he  removed 
per  vaginam  a  septic  inverted  uterus. 

Pulmonary  Embolism. 

Amongst  the  most  fatal  accidents  following  on  parturition  is 
pulmonary  embolism.  This  complication  is  due  to  the  dislodgment 
of  a  portion  of  thrombus  from  some  of  the  pelvic  veins.  It  usually 
occurs  in  the  third  week  of  the  puerperium,  but  occasionally  it  takes 
place  immediately  after  delivery.  No  matter  Avhen  the  accident 
occurs,  the  condition  is  an  extremely  grave  one,  and  the  vast  majority 
of  patients  attacked  die.  The  disease  will  be  best  illustrated  b}T 
recording  two  cases  from  my  practice.  In  the  first  the  accident 
happened  at  the  end  of  the  second  week,  and  in  the  second  immedi- 
ately after  delivery. 

Case  1. — Case  of  Death  on  the  Fourteenth  Day  of  the  Puerperium  from 

Pulmonary  Embolism. — Mrs.  B ,  aged   thirty-four,  4-para,  had   been  a 

patient  of  mine  for  several  years.  She  first  came  under  my  care  in  her 
second  pregnancy,  which  terminated  in  a  miscarriage  at  the  fourth  month. 
Her  first  pregnancy,  she  informed  me,  had  ended  at  full  time,  when  she  was 
delivered  with  forceps  of  a  large  male  stillborn  child.  Her  third  pregnancy 
also  terminated  in  an  abortion  at  the  fourth  month.  During  her  fourth 
pregnancy   she   was    troubled    greatly    with    digestive    disturbances,    and 

1  Trans.  Lond.  Obst.  Soc,  vol.  xlvi.,  p.  206. 

-  Anal  de  Gun.  et  cVObst.,  May,  1906,  p.  25. 

3  Journ.  Obst.  and  Gyn.  Brit.  Empire,  March,  1907,  p.  24s. 


662  OPERATIVE  MIDWIFERI 

towards  the  end  by  albuminuria,  and  even  a  threatening  of  eclampsia.     With 
suitable  treatment,  however,  Bhe  escaped  the  latter,  and  her  pregnancy 
allowed  to  continue  until  full  time,  when  Bhe  was  delivered  with  forceps 
living  child.     During  the  whole  of  her  pregnancy  she  was  taken  great 
of.     The   puerperium  was  a  little   unsatisfactory.     The  pulse  wae  alwj 
rapid,   usually   about   90,  ami   the   temperature   always   a    little    raised — 
'•''•''•">°  to  100°  F.     <  )u  several  occasions  the  uterus  was  douched  with  mercuric 
chloride.     Gradually  the  temperature  and  pulse  subsided,  but  never  quite 
returned  to  the  normal.     At  the  end  of  the  second  week  she  complained  of  a 
little  pain  in  the  left  iliac  region,  and  she  was  warned  not  t<>  rise.     On  the 
thirteenth   day,  however,  contrary   to  my  instructions,  she  insisted  upon 
being  lifted  into  an  arm-chair,  and  the  same  thing  was  done  on  the  four- 
teenth day.     On  the  hitter  day  she  felt  so  well  sitting  in  the  chair  that  she 
actually  tried  to  walk  a  little.     After  going  a  few  steps  she  was  suddenly 
seized  with  great  precordial  pain  and  dyspneea.     She  was  immediately  lifted 
into  bed  by  her  husband  and  the  nurse,  but  the  breathlessness  and  pain 
continued.     I  reached  her  house  about  half  an  hour  after  the  occurrence. 
She  was,  however,  dead  before  I  reached  her — at  least,  she  gave  one  last 
gasp  as  I  entered  her  bedroom. 

At  the  post-mortem  examination  both  pulmonary  arteries  contained  large 
Hood-clots;  the  left  iliac  vessels  were  thrombosed.  Both  kidneys  were 
extensively  diseased,  the  right  being  replaced  almost  entirely  by  cysts  :  the 
left  also  contained  many  cysts,  and  was  much  enlarged. 

Case  2. — Pulmonary  Embolism  immediately  after  Delivery — Recovery. — This 
patient  complained  of  pain  and  breathlessness  shortly  after  her  delivery. 
She  was  a  primipara  with  a  slight  justo-minor  pelvis.  On  examining  her 
under  chloroform  about  the  thirty-sixth  week,  it  was  deemed  advisable, 
because  of  the  relative  size  of  the  head  and  the  pelvis,  to  induce  labour. 
This  was  done  with  a  bougie.  Labour  came  on  in  a  few  hours,  and 
terminated  spontaneously  within  a  very  short  period.  After  giving  the 
placenta  fully  an  hour  to  separate,  I  introduced  my  hand  into  the  uterus 
and  found  it  slightly  adherent.  I  removed  the  placenta  without  much 
difficulty.  When  the  patient  recovered  from  the  anaesthesia,  she  complained 
of  precordial  pain  and  breathlessness.  This  became  steadily  worse,  and  the 
pulse  became  more  rapid.  After  a  hypodermic  injection  of  ]  grain  of  morphia 
the  pain  was  relieved,  but  she  still  remained  very  breathless,  and  could  not 
lie  down  comfortably  in  bed.  Inhalations  of  oxygen  from  time  to  time  gave 
her  some  relief.  She  made  a  somewhat  slow  recovery,  but  there  were  no 
further  complications.  The  temperature  was  normal  throughout  the  whole 
puerperium. 

A  severe  case  of  pulmonary  embolism  can  hardly  be  mistaken  for 
any  other  condition.  The  sudden  onset,  the  severe  precordial  pain, 
the  great  dyspnoea,  and  the  increasing  lividity,  render  the  diagnosis 
self-evident.  In  the  slighter  forms  of  the  accident,  however,  there 
may  be  some  doubt.  For  instance,  I  have  twice  seen  patients  seized 
with  hysterical  attacks  of  dyspnoea  which  very  closely  resembled  the 


PULMONARY  EMBOLISM  663 

lyspncea  of  pulmonary  embolism.  It  is  always,  of  course,  open  to 
loubt  whether  these  attacks  were  really  hysterical.  In  one  case, 
aowever,  they  were  quite  certainly  of  this  nature,  as  the  patient  had 
several,  one  some  weeks  after  her  confinement,  when  she  received  the 
news  that  her  husband  was  suddenly  ordered  abroad  with  his 
regiment.  The  other  patient  was  undoubtedly  neurotic  also,  and  has 
had  peculiar  nervous  symptoms  at  different  times  while  she  has  been 
under  my  care. 

Very  occasionally  the  embolus  consists  not  of  blood-clot,  but  of  air. 
The  symptoms  are  analogous.  The  air  is  introduced  during  intra- 
uterine manipulations,  as  in  cases  of  placenta  praevia,  version,  and 
especially  in  removing  an  adherent  placenta. 

Serious,  and  even  fatal,  dyspncea  may  also  follow  the  insufflation 
of  vomited  material. 

A  very  grave  condition  indeed,  and  one  which  may  give  rise  to 
sudden  death,  is  acute  oedema  of  the  lungs.  Some  little  time  ago  I 
was  asked  to  see  such  a  case  in  consultation,  but  the  patient  was 
dead  before  I  reached  her  house.  The  quantities  of  frothy  mucus 
from  the  respiratory  passages  is  a  very  striking  feature  of  this 
condition. 

The  treatment  of  this  most  serious  accident  of  pulmonary 
embolism  consists  in  keeping  the  patient  at  absolute  rest.  She  must 
on  no  account  be  allowed  to  move  ;  everything  must  be  done  for  her. 
The  pain  complained  of  over  the  pericordial  region  is  best  relieved  by 
the  administration  of  morphia  hypodermically.  Inhalations  of  oxygen 
are  also  of  value,  although  there  is  often  not  time  to  obtain  cylinders, 
as  death  frequently  takes  place  within  a  few  minutes.  Intracellular 
saline  transfusion  to  dilute  the  blood  is  recommended  by  many 
writers,  but  none  now  attach  much  value  to  the  liquor  ammonia 
or  the  alkalis  formerly  advocated.  If  the  patient  at  any  time  shows 
signs  of  collapse,  stimulants  must  be  given  by  the  mouth  and  strych- 
nine hypodermically. 

Subcutaneous  Emphysema. 

This  complication  is  one  of  considerable  rarity,  although  it  is 
probable  that  slighter  examples  of  the  condition  are  often  overlooked. 
Many  interesting  monographs  have  appeared  since  Depaul  published 
the  first  exhaustive  memoir  on  the  subject  in  1842.  In  recent  years 
Klots,1  Hergott,2  Stevens,3  and  Kosmak,4  amongst  others,  have  made 

1  Zeit.f.  Gel.  u,  Gyn.,  1899,  Bd.  xli.,  Heft  3. 

2  Ann.  de  Gyn.  et  cVObst.,  1904,  p.  641. 

3  Trans.  Med.-Chir.  Soc,  Glasgow,  vol.  iii.,  p.  99. 

4  Bulletin,  L/ying-in  Hospital,  New  York.  1907,  vol.  iii. 


664  OPERATIVE  MIDWIFERY 

interesting  communications.  Klote  has  collected  forty  cases  and 
ELosmak  seventy-seven.  The  genera]  view  held  is  that  the  condition 
arises  from  rupture  of  the  air  vesicles  at  the  root  of  the  lung, 
air,  therefore,  escapes  underneath  the  pulmonary  pleura  into  tin- 
anterior  mediastinum,  and  bo  underneath  the  cervical  fascia  up  over 
the  neck  and  chest.  Their  are,  however,  some  who  believe  that  the 
condition  is  due  to  injuries  to  the  respiratory  tract  higher  up — for 
example,  in  the  mouth  and  trachea. 

Judging  by  the  published  cases,  the  patients  wire  invariably 
primiparsB.  In  all  there  were  considerable  straining  efforts  made  during 
the  second  stage.     In  many  the  labours  terminated  spontaneously. 

The  condition  is  undoubtedly  favoured  where  resistance  is  inert 
owing  to  the  child  being  of  exceptionally  large  size,  or  the  pelvis  being 
unusually  small,  and  the  soft  parts  unduly  rigid.  In  a  considerable 
number  of  cases  pain  is  complained  of,  and  is  very  often  situated  about 
the  region  of  the  seventh  or  eighth  rib.  The  outlook  is  good,  the 
patients  invariably  recovering.  No  very  special  treatment  is  required, 
but  if  the  pain  is  excessive  during  breathing,  the  affected  side  should 
be  firmly  strapped,  as  is  done  in  cases  of  fractured  ribs. 

The  following  two  cases  illustrate  this  condition  : 

Case  1. — Mrs.  X was  delivered  of  a  first  child  in  October,    1902. 

Distinct  labour  pains  began  about  10  p.m.,  and  the  child  was  born  six  hours 
later.  The  first  stage  was  of  short  duration.  Soon  after  the  second  -;  _ 
began  the  pains  became  very  severe,  with  strong  expulsive  efforts.  About 
three  hours  before  delivery  a  slight  swelling  of  the  neck  was  noticed,  and 
increased  until  the  birth  of  the  child,  which  occurred  spontaneously.  Shortly 
after  delivery  the  patient  complained  of  severe  pain  over  the  right  side, 
in  the  region  of  the  seventh  and  eighth  ribs,  about  2  inches  outside  the 
nipple-line.  The  swelling  in  the  neck  had  by  this  time  increased,  and  had 
extended  up  the  sides  of  the  head  and  down  over  the  chest,  back  and  front. 
Over  this  whole  puffy  area  crepitation  could  be  elicited.  The  pain  in  the 
side  continued  for  several  days,  and  the  emphysema  entirely  disappeared 
within  a  week.  There  was  no  cough  nor  expectoration,  and  the  patient 
made  an  uninterrupted  recovery. 

Case  2. — A.  M ,  aged  twenty-nine,  a  primipara,  was  a  patient  in  my 

wards  in  September,  1905.  The  presentation  was  normal  and  the  birth 
spontaneous.  The  first  stage  lasted  some  thirty-six  hours,  but  was  not 
unduly  severe.     The  second  stage  was  not  specially  delayed,  but  the  patient 

earned  excessively,  and  for  half  an  hour  before  her  child  was  born  had 
extremely  severe  pains.  About  half  an  hour  before  delivery  Bhe  noticed  a 
swelling  in  the  neck,  and  had  a  choking  sensation.  This  swelling  in  the 
neck  extended  upwards  over  her  cheek  and  eyelid-,  and  downwards  over 
her  chest.     She  complained  of  slight  pain  in  her  left  side,     she  directed  the 


SUBCUTANEOUS  EMPHYSEMA  665 

house-surgeon's  attention  to  the  swelling  after  her  delivery.  It  was  then 
found  that  over  the  swollen  area  there  was  distinct  emphysema.  The 
swelling  disappeared  in  a  few  days,  and  the  patient  made  an  uninterrupted 
recovery. 

In  cases  of  rupture  of  the  uterus  there  is  a  variety  of  subcutaneous 
emphysema  occasionally  encountered.  The  air  in  such  cases  gets  into 
the  cellular  tissue  of  the  broad  ligament  and  abdominal  wall. 


<  BAPTEB  XXXVII 

ACCIDENTS  TO  CHILD  :  INJURIES  TO  BONES,  MUSCLES,  NERVES, 
VISCERA,  ETC.  ;  ASPHYXIA  NEONATORUM 

All  manner  of  injuries  may  follow  a  difficult  delivery  terminated  by 
forceps,  or  by  traction  on  the  breech  and  after-coming  head.  Amongst 
the  least  serious  are  bruises  and  lacerations  of  the  scalp,  face,  and 
other  soft  parts. 

Caput  Succedaneum  and  Cephalo-Haematoma. 

These  simple  conditions  are  familiar  to  everyone.  The  caput 
succedaneum  forms  over  the  presenting  part.  It  is  an  a-dematous 
swelling  of  the  superficial  tissues  which  arises  in  most  of  the  cases 
after  the  membranes  have  ruptured,  and  increases  in  size  the  longer 
the  second  stage  continues.  The  swelling  is  a  harmless  one,  and 
disappears  in  a  few  days. 

A  cephalo-hamatoma,  on  the  other  hand,  is  a  collection  of  blood 
underneath  the  pericranium.  It  is  to  be  distinguished  from  the  caput 
succedaneum  by  the  fact  that  it  generally  does  not  appear  until  a  day 
or  two  after  delivery,  is  limited  to  particular  bones  by  the  attachment 
of  the  periosteum,  and  is  most  common  when  parturition  is  easy  and 
rapid.  In  most  cases  it  forms  over  one  parietal  bone,  but  sometimes 
both  are  affected,  and  occasionally  it  is  found  on  the  occipital  and 
frontal  bones.  The  swelling  is  a  fluctuant  one  and  often  takes  weeks 
to  disappear.  At  the  edges  of  the  swelling  an  irregular  ossification 
occurs,  so  that  a  round,  hard,  raised  edge  may  be  felt.  Occasionally  a 
more  diffuse  ossification  occurs,  so  that  crepitation  may  be  elicited  over 
the  tumour.     Very  occasionally  the  swelling  becomes  infected. 

Some  writers  have  recommended  puncture,  aspiration  of  the  blood, 
and  the  application  of  a  firm  binder  or  strapping.  The  effusion  need 
not  be  interfered  with,  however,  unless  suppuration  occurs,  when  the 
sac  should  be  freely  opened  and  packed  with  gauze. 

Injuries  to  Nose,  Ear,  and  Eyes. 

More  serious  injuries  are  fractures  of  the  nose,  lacerations,  and 
even  complete  removal,  of  the  ear,  and  injuries  to  the  eyeball.    These 

666  i 


ACCIDENTS  TO  CHILD  667 

a  variably  result  from  forcible  extraction  of  the  child  with  forceps  in 
■ontracted  pelvis.  Fracture  of  the  nose  may  possibly  occur  even  in 
■pontaneous  delivery,  but  tearing  or  removal  of  an  ear  only  results  in  a 
orceps  delivery  when  one  of  the  blades  slips.  These  accidents  are 
ixtremely  rare. 

Injuries  to  the  eye  are  often  very  serious ;  slight  lacerations  of  the 
syelid  are  not  of  much  consequence,  but  sometimes  it  happens  that 
he  eyeball  is  burst  or  even  completely  evulsed.  Several  interesting 
irticles  have  been  written  by  Buchanan  and  Thomson1  on  the  subject 
if  corneal  opacity  following  forceps  deliveries.  They  have  pointed  out 
hat  a  general  cloudiness  of  the  cornea  often  occurs,  which  finally 
■ettles  down  into  a  linear  cicatrix.  Undoubtedly,  in  many  cases  the 
njuries  to  the  eye  are  directly  produced  by  a  blade  of  the  forceps  ; 
>ut  in  not  a  few  cases,  especially  those  in  which  evulsion  of  the  eye 
>ccurs,  the  accident  results  from  extreme  compression  of  the  head,  as 
vhen  a  child  is  dragged  through  a  deformed  pelvis. 

Injuries  to  the  Bones. 

Fracture  of  the  Skull. — Injuries  of  the  bones  of  the  skull  almost 
nvariably  occur  during  parturition,  and  most  commonly  when  there 
las  been  difficulty  in  extracting  the  fore-coming  head  by  forceps  or 
he  after-coming  head  by  traction.  Very  occasionally  it  happens  that 
ractures  of  the  skull  occur  during  pregnancy  as  a  result  of  falls  or 
•lows  sustained  by  the  mother.  In  such  cases  the  head  of  the  child, 
till  movable  in  the  uterus,  is  suddenly  driven  against  the  brim  of 
he  pelvis  or  the  vertebral  column.  The  child  may  be  killed  by  the 
■ccident,  which  is  often  so  severe  as  to  bring  on  premature  labour  : 
ut  in  not  a  few  cases  the  pregnancy  has  continued  undisturbed  and 
he  child  has  recovered,  the  injuries  having  healed  in  utero. 

In  most  cases,  when  injuries  occur  during  parturition,  the  labour 
ias  been  protracted  owing  to  the  disproportion  between  the  foatal  head 
nd  the  maternal  pelvis.  In  some  the  force  of  the  uterine  contractions 
as  been  sufficient  to  overcome  this  obstruction  in  the  parturient  canal, 
nd  the  injuries,  therefore,  may  be  described  as  spontaneous.  In  most 
ases,  however,  the  delivery  has  been  artificially  terminated  by  forceps 
r  traction  on  the  lower  limbs,  and  the  injuries  are,  therefore,  of  a 
iolent  nature.  I  have  seen  occasionally  very  extensive  fractures 
irectly  produced  by  the  blades  of  the  forceps.  In  such  cases  the 
hild's  head  has  usually  been  grasped  obliquely,  and  the  tips  of  the 
lades  have  been  the  cause  of  the  injuries.  The  occipital  and  frontal 
ones    then   suffer   most.     Sometimes,    however,    although   fractures 

1   Trans.  Ophthal.  Soc,  vol.  xxiii. 


OPEBATIVE  MlhWll  i:i;V 

occur,  the  forceps  Le  not  primarily  to  blame;  fche  injury  really  ari 
from  dragging  the  child  past  the  projecting  promontory.     In  t 

-  the  parietal  and  frontal  bones  are  those  usually  injured.  A 
most  serious  injury  is  separation  of  the  condyloid  process  of  the 
occipital  bone.  It  usually  occurs  when  there  is  difficulty  in  extracting 
the  ufter-coming  head.  In  this  condition  death  may  result  from  intra- 
cranial hemorrhage  or  from  direct  injury  to  the  medulla.  Another 
very  serious  and  fatal  accident  is  dislocation  of  the  upper  cervical 
vertebra. 

Indentations  of  Skull. — Indentations  of  the  skull  are  either 
furrow-shaped  or  spoon-shaped.  The  furrow-shaped  variety  are  less 
serious,  and  seldom  give  rise  to  much  immediate  disturbance.  They 
may  be  of  various  forms.  They  are  sometimes  confined  to  the  parietal 
or  frontal  bones,  but  very  often  involve  both. 

Much  more  serious  are  the  spoon-shaped  indentations,  for,  in  many 
cases,  they  are  associated  with  fracture  of  the  indented  portion  of 
bone. 

The  subject  of  indentations  of  the  skull  of  the  new-born  has  been 
frequently  written  about,  more  particularly  by  French  obstetrician-. 
I  considered  the  subject  in  some  detail  a  few  jrears  ago.1  The  injury 
is  usually  situated  on  one  or  other  of  the  parietal  or  frontal  bones  in 
the  neighbourhood  of  the  anterior  fontanelle.  "With  few  exceptions,  it 
occurs  where  there  is  deformity  of  the  maternal  pelvis,  most  commonly 
a  deformity  of  only  a  moderate  degree.  The  indentation  is  usually 
caused  by  the  head  being  pressed  or  pulled  against  the  projecting 
sacral  promontory.  Apart  from  bony  deformity,  it  would  appear  that 
the  condition  has  occasionally  been  produced  by  tetanic  contractions  I 
of  the  uterus,  contractions  of  the  muscles  of  the  pelvic  floor,  ankylosis 
of  the  coccyx,  and  tumours  of  the  bones  and  soft  parts  of  the  pelvis. 
On  the  foetal  side,  Budin  has  recorded  a  case  of  twins  where  the  after- 
coming  head  of  the  first  child,  which  presented  by  the  breech,  was 
arrested  by  the  presenting  head  of  the  second ;  both  the  children  were 
born  dead,  with  depressions  of  their  skulls.  Braune-  reported  a  case 
where  the  depression  was  caused  by  an  arm  prolapsed  at  the  side  of 
the  head.  Occasionally  the  accident  has  recurred  in  succeeding 
labours.  Strassmann3  has  recorded  a  case  where  a  woman  gave 
birth  on  five  different  occasions  to  children  with  depressions  of  their 
skulls. 

No  doubt  defective  ossification  of  the  skull  predisposes  to  the 
accident.     Experimenting  on  stillborn  infants  I  found  I  could  produce 

1  Brit.  Med.  Jouni.,  January  19,  1901,  and  Edin.  Obst.  Trans.,  vol.  xwi..  p.  12. 

-  Zentf.  Gyn.,  1896,  p.  225. 

3  Zcit.f.  Geb.  u.  Gyn.,  1900,  Bd.  xlii.,  Heft  8,  p.  615. 


ACCIDENTS  TO  CHILD  669 

epression  with  little  pressure  in  some  cases,  but  in  others  I  could 
nake  no  impression  on  the  bones  at  all,  even  although  I  used 
onsiderable  force. 

In  the  majority  of  forceps  deliveries,  as  I  have  already  indicated, 
t  is  the  pressure  of  the  head  against  the  promontory,  not  the  blades, 
hat  causes  the  injury. 

The  effect  of  these  injuries  upon  the  child  varies.  In  some  cases 
hey  cause  death.  When  the  children  are  born  alive,  the  indentations 
ometimes  disappear  spontaneous!}'  in  a  week  or  ten  days.  In  such 
ases  there  has  probably  been  no  real  fracture  of  the  bone  ;  it  has  been 
simple  indentation.  Most  commonly  the  depressions  remain,  but 
ause  no  immediate  or  late  disturbance.  On  other  occasions  they  give 
ise  to  more  or  less  severe  nervous  phenomena,  and  later  in  life  to 
>ermanent  mental  -weakness. 

Here  are  two  illustrative  cases  : 

(ask  1. — Some  years  ago  I  delivered  a  mature  child  with  forceps 
hrough  a  slightly  flat  rachitic  pelvis.  The  child  was  born  with  a  spoon- 
haped  depression  over  the  right  frontal  bone  ;  it  seemed  otherwise  well, 
t  did  not  thrive,  however,  and  about  a  fortnight  after  its  birth  took  a  few 
onvulsive  seizures  and  died. 

Case  2. — Some  months  after  the  above  case  occurred,  Dr.  Malcolm 
Black,  Consulting  Physician  to  the  Maternity  Hospital,  told  me  of  a  case  in 
vhich  he  had  great  difficult}'  in  extracting  the  head  with  forceps,  owing  to  a 
leformity  of  the  pelvis.  There  was  a  large  spoon-shaped  depression  over 
he  left  frontal  bone  ;  the  child's  heart  was  beating  very  slightly,  and  artificial 
espiration  brought  about  little  improvement  in  its  condition.  Recollecting 
ay  request,  he  tried  compression  of  the  skull,  with  the  result  that  the 
adentation  came  up  suddenly  with  a  jerk,  the  child  immediately  began  to 
nake  attempts  at  respiration,  the  heart  commenced  to  beat  more  strongly, 
aid  before  long  the  child  was  quite  out  of  danger. 

Removal  of  Indentation. — At  one  time  I  was  not  in  the  habit  of 
nterfering  with  cases  of  spoon-shaped  indentations,  but  in  recent 
/ears  I  have  almost  invariably  operated  upon  them.  When  I  made 
.he  contribution  already  referred  to,  I  suggested  a  simple  treatment 
vhich  I  had  found  successful — viz.,  very  firm  antero-posterior  com- 
pression of  the  head  (Fig.  295).  This  simple  procedure,  which  often 
succeeds,  I  discovered  accidentally  at  a  confinement  of  a  private 
)atient.     This  briefly  is  a  history  of  the  case  : 

A  child  which  was  of  average  size  and  full  time  was  extracted  with 
orceps,  the  indication  for  the  latter  being  a  persistent  oecipito-posterior 
n-esentation.  On  extracting  the  child  I  discovered  a  deep  spoon-shaped 
ndentation  on  its  right  frontal  bone.  The  child  was  only  slightly 
isphyxiated,  and  soon  cried  and  seemed  little  disturbed  by  the  deformity. 


670 


OPERATIVE   Mlh\VIIKl;Y 


While  looking  at  the  indentation,  it  occurred  tome  that  by  firmly  compn 
ing  the  head  antero-posteriorly,  sufficient   pressure  might  be  exerted  on  the 
depressed  bone  to  cause    it   to  spring   up.     I   hardly  expected   the  simple 
manoeuvre  to  be  bo  successful,  but  <m  the  first  attempl  the  depression  came 
"in.  producing  a  Bound  as  when  a  dent  in  a  felt  hat  is  removed. 

I  Hiring  recent  years  I  have  had  several  equally  good  results  from 
this  treatment,  although  in  not  a  few  cases  it  has  failed.     Several 


Fig.  295. —  Indentation  of  Frontal  Bone  removed  by  Antero-Posterior  Compression. 

(Author's  case.) 


confreres  have  told  me  of  successes,  but  many  also  have  told  me 
of  failures.  In  all  probability  success  or  failure  depends  upon  the 
degree  of  ossification  of  the  cranial  bones,  and  the  presence  or  absence 
of  fracture.  In  carrying  out  the  treatment  I  use  very  firm  pressure 
indeed,  and  in  two  of  the  cases  I  have  succeeded  in  bringing  out  the 
indentation  when  a  confrere  failed. 

All  manner  of  instruments  have  been  suggested  for  removing  the 
indentation.     Sir  James  Simpson,  for  example,  recommended  an  air- 


ACCIDENTS  TO  CHILD 


(571 


ractor.  The  simplest  of  all  devices,  however,  is  that  employed  by 
.Veedy.1  One  blade  of  a  vulsellum  forceps  is  bored  through  the  hone  ; 
he  point  of  the  instrument  is  then  turned  round,  and  the  indentation 
mlled  up. 

Major  Operatiec  Treatment. — The  oldest  references  to  major  opera- 
ive  treatment  on  cranial  indentations  in  the  new-born  is,  as  fur  as  I 
an  find,  the  case  reported  by  Tapret  in  1877.  Boissard'2  describes  the 
ase.  There  was  a  marked  depression,  with  fracture  of  the  left  parietal 
>one,  left  exophthalmos,  and  right  facial  paralysis.     The  child  cried 


Fig.   296. — Indentation  of  Skull  removed  by  Operation. 


/ery  feebly.  M.  Millard  bored  through  the  skull  and  raised  the 
lepressed  bone,  with  the  result  that  the  child  cried  immediately.  The 
convulsions  ceased,  the  exophthalmos  gradually  disappeared,  and  on 
;he  following  day  only  a  trace  of  the  facial  paralysis  remained.  In 
-ecent  years  a  number  of  successful  cases  have  been  recorded.  In 
some  the  operator  has  trephined  over  the  depression,  in  others 
ae  |_has  incised  the  skull  along  the  margin  of  the  depression.  All 
nanner  of  instruments  have  been  used  for  raising  the  bone.  In  most 
3ases,  when  the  operation  is  undertaken  immediately,  the  bone  is 
very  easily  raised,  but  after  a  few  days  it  becomes  increasingly  more 
lifficult. 

1  'Rotunda  Practical  Midwifery,'  1908,  p.  311. 

2  '  Lelievre's  These,'  Paris,  1892. 


672  OPERATIVE  MIDWIFER1 

The  method  1  have  employed  in  the  Maternity  Hospital  is  the 
making  of  an  incision  through  the  Bcalp  and  pericranium  along  the 
margin  of  the  depression,  cutting  the  hone  with  Bharp  Bcissors,  and 

then  inserting  a  fiat  elevator  between  the  dura  mater  and  skull.  In 
the  illustration  (Fig.  296)  is  seen  the  result  from  such  an  operation. 

There  is  no  Hap  turned  down  ;  if  this  is  necessary,  then  the  incision 
would  be  made  along  the  upper  margin  of  indentation. 

For  cases  seen  some  time  after  the  occurrence  of  the  accident  an 
ingenious  device  is  that  suggested  by  Nicoll.1  A  flap  of  the  scalp  and 
pericranium  is  turned  down,  and  the  indented  portion  of  the  bone  is 
cut  out  with  a  trephine.  The  excised  portion  of  the  bone  is  reversed 
and  then  replaced.  The  scalp  and  pericranium  are  then  brought  over 
the  bone  and  stitched. 

Injuries  to  Other  Bones. — I  have  only  once  observed  fracture  of 
the  lower  jaw  ;  it  was  caused  by  the  tip  of  the  blade  of  the  forceps. 
The  bones  which  are  most  liable  to  be  fractured  are  the  clavicle, 
humerus,  and  femur.  The  accident  most  generally  occurs  in  bringing 
down  the  limbs  in  breech  presentations. 

It  would  appear  from  the  investigation  of  Eiether2  and  Muus3  that 
fracture  of  the  clavicle  is  bjT  no  means  uncommon.  As  it  frequentl}* 
causes  little  discomfort  to  the  patient  and  does  not  prevent  its  moving 
its  arms,  the  condition  is  often  overlooked.  Occasionally  it  occurs  in 
spontaneous  births,  but  usually  it  follows  difficult  extraction  of  the 
shoulders,  when  the  child  is  large  in  size  or  the  passage  is  narrow. 

The  clavicle  fractures  are  generally  incomplete,  but  those  of  the 
humerus  and  thigh  are  often  complete,  for  the  bone  is  broken  right 
across.  In  dealing  with  fractures  of  the  clavicle  and  the  humerus  the 
child's  arm  should  be  firnily  bound  against  the  trunk.  Fractures  of 
the  lower  limbs  are  more  difficult  to  treat,  as  Jones4  of  Liverpool  has 
recently  pointed  out. 

Injuries  to  Muscles. 

Although  tears  and  lacerations  of  any  of  the  muscles  may  occur 
in  difficult  deliveries,  more  especially  difficult  breech  deliveries,  the 
only  one  which  requires  special  mention  is  that  of  the  sterno-mastoid. 
Injuries  to  this  muscle  are  followed  by  the  development  in  its  substance 
of  a  hematoma.  This  accident  may  occur  in  head-first  and  in  head- 
last  deliveries.  In  head-first  deliveries  it  is  produced  in  very  much 
the  same  manner  as   'birth  paralysis'   (p.  077).     The  hematoma   i- 

1  Trans.  Glas.  Med.-Chir.  Soc,  vol.  iv.,  p.  421. 
-   Wien.  Kim.  Woch.,  .tune  12,  1902.  No.  21. 

Zentf.  (iijn.,  1903,  No.  23. 
i  Brit.  Med.  Jowrn.,  1908,  vol.  i..  p.  1 


ACCIDENTS  TO  CHILD  673 

ften  not  noticed  for  some  little  time  after  the  birth.  It  usually  takes 
■me  to  disappear,  but  clears  up  completely  and  leaves  no  bad  effects, 
•ccasionally  it  is  the  cause  of  torticollis. 

Injuries  to  Brain,  Spinal  Cord,  Nerves. 

Haemorrhage  into  the  Cranial  Cavity. — As  might  be  expected, 
itracranial  haemorrhages  are  most  frequently  the  result  of  difficult 
nd  artificial  deliveries.  It  occasionally  happens,  however,  that  these 
:aemorrhages  take  place  in  easy  and  spontaneous  births.  All  writers, 
lcluding  Gowers,1  refer  to  the  fact  that  in  not  a  few  cases  labour  was 
■recipitate.  According  to  Seitz,2  in  20  per  cent,  of  cases  this  was  so. 
lS  might  be  expected,  the  occurrence  is  more  frequent  with  boys  than 
/ith  girls. 

Haemorrhages  into  the  substance  of  the  brain  are  not  common.  For 
he  most  part  they  are  meningeal,  and  are  generally  situated  over  the 
urface  of  the  convexity  of  the  brain,  although  not  infrequently  they 
re  found  also  at  the  base.  According  to  Gowers,  when  the  haenior- 
hage  is  over  the  convexity  of  the  brain,  it  is  generally  bilateral, 
,nd  is  most  considerable  over  the  central  region  and  towards  the 
aiddle  line.  This  is  in  agreement  with  Spencer's  findings.3  Gushing4 
tates,  although  evidently  it  is  only  an  impression,  not  a  conviction 
rom  observations  made  :  '  I  am  of  opinion  that  the  extravasation  is 
isually  limited  to  one  side  of  the  falx,  though,  indeed,  a  bilateral 
esion  is  common  enough,  as  the  many  patients  with  diplegia  would 
adicate.'  It  will  be  observed  that  in  two  of  the  four  cases  described 
y  dishing  there  was  extensive  haemorrhage  over  both  hemispheres, 
,nd  it  is  very  possible  in  Case  1  that  this  was  so  also.  Seitz  also  says 
hey  are  mostly  unilateral,  but  he  only  speaks  from  six  cases.  This 
uestion,  as  to  whether  the  haemorrhages  are  generally  unilateral 
>r  bilateral,  has  become  a  matter  of  practical  importance  since 
perative  treatment  has  been  advocated  by  Cushing,  Carmichael,5 
teitz,  and  others.     I  shall  refer  to  this  later. 

In  a  very  large  proportion  of  cases  the  haemorrhage  is  associated 
nth  asphyxia  neonatorum.  No  doubt  in  many  the  haemorrhages  are 
he  result  of  the  asphyxia,  for  in  a  very  large  proportion  of  cases  the 
laemorrhages  are  not  limited  to  the  cranium,  but  are  found  in  kidneys, 

1  '  Diseases  of  Nervous  System,'  vol.  ii.,  p.  414. 

2  Zent.f.  Gyn.,  1907,  No.  26,  p.  780. 

3  '  Visceral  Haemorrhages  in  Stillborn  Children  :  an  Analysis  of  130  Autopsies.' 
]rans.  Lond.  Obst.  Soc.,  1892,  vol.  xxxiii. 

4  '  Concerning  Surgical  Intervention  for  the  Intracranial  Hemorrhages  of  the 
Jew-born,'  Amer.  Journ.  Med.  Sciences,  October,  1905. 

6  Trans.  Edin.  Obst.  Soc,  xxxi.,  p.  105. 

43 


674  OPERATIVE  MIDWll  K1;Y 

liver,  spleen,  intestines,  uterus,  etc.  It  must,  however,  lje  admitted, 
I  think,  that  in  a  certain  number  the  hemorrhages  are  the  cause  of 
the  asphyxia. 

Without  doubt,  as  has  been  indicated  already,  in  a  very  large  pro- 
portion of  cases  direct  external  violence  has  been  the  cause  of  the 
haemorrhage ;  but  apart  from  this  cause,  there  are  other  factors  than 
violence,  such  as  the  delicacy  of  the  vessel  walls,  and  the  mobility 
between  the  different  bones  of  the  fcetal  skull.  This  latter  factor  is  a 
matter  of  extreme  importance.  "When  the  head  moulds,  the  parietal 
bones  overlap  and  are  pushed  over  or  under  the  frontal  and  occipital 
bones.  Both  Gowers  and  Cushing  explain  the  frequency  of  these 
haemorrhages  over  the  upper  aspect  of  the  hemispheres  by  the  over- 
lapping of  the  parietal  bones.  By  this  overlapping  the  veins  which 
ascend  over  the  cortex  and  open  into  the  longitudinal  sinus  are  torn 
before  their  entrance  into  the  latter ;  it  may  even  happen  that  some- 
times the  sinus  itself  is  torn. 

Spencer1  says:  'There  are,  however,  two  conditions  to  which  I 
wish  to  draw  special  attention  as  determining  causes  of  meningeal 
haemorrhage — namely,  softness  of  the  skull  bones  and  increased 
mobility  of  the  bones  from  laxity  of  the  sutures,  and  particularly  of 
the  lower  edge  of  the  parietal  bone.  .  .  . 

'  As  stated  above,  in  eleven  instances  the  ha?morrhage  was  found 
limited  to  the  parietal  region  of  the  Sylvian  fissure — that  is,  to  the 
part  drawn  by  the  great  anastomotic  vein.  In  many  of  these  cases  it 
was  obvious  that  the  effusion  was  due  to  the  clamping  of  the  vein 
from  the  pressure  of  the  lower  anterior  corner  of  the  parietal  bone, 
which  immediately  overlies  the  main  trunk  of  the  vessel.  In  other 
cases,  where  the  haemorrhage  was  more  diffuse,  it  is  more  than 
probable  that  the  depressibility  of  this  part  of  the  bone  was  an 
important  factor  in  the  causation  of  the  haemorrhage,  though  it  was- 
less  demonstrable  than  in  the  cases  just  mentioned. 

'  The  above  observation  leads  me  to  regard  the  part  occupied  by  the 
lower  anterior  portion  of  the  parietal  bone  as  the  most  vulnerable 
part  of  the  child's  head.' 

The  symptoms  of  cerebral  haemorrhage  are  by  no  means  constant. 
If  the  haemorrhage  is  very  extensive,  symptoms  may  show  themselves 
immediately  after  birth,  but  in  not  a  few  cases  symptoms  have  not 
appeared  till  some  days  after  delivery.  Where  the  intracranial 
pressure  is  great  the  anterior  fontanelle  is  very  tense,  the  bony  outline 
of  the  space  cannot  be  defined,  and  pulsation  is  absent.  The  eye- 
balls  often  protrude  and  the  lids  are  cedematous.  Convulsions  are 
frequent,  but  rarely  appear   until  some  time  after  delivery.     These 

1  Op.  cit.,  p.  268. 


ACCIDENTS  TO  CHILD  G75 

onvulsions  are  often  accompanied  by  rigidity  of  the  limbs.  If  the 
:hild  recovers,  they  usually  cease  after  a  week  or  two.  With  great 
ncrease  of  intracranial  pressure  the  child  becomes  progressively 
vorse.  It  refuses  to  take  its  food,  becomes  increasingly  listless  and 
Irowsy,  and  finally  sinks  into  a  condition  of  coma.  The  history  of  a 
lifficult  delivery  will  often  help  the  diagnosis,  but,  let  me  again  remark, 
he  occurrence  may  take  place  in  precipitate  labours.  A  valuable 
lid  to  diagnosis  is  lumbar  puncture,  for  with  intracranial  haemorrhage 
he  fluid  withdrawn  will  be  blood-stained. 

In  recent  years  several  writers,  as  I  have  already  stated,  have 
ecommended  operative  treatment  for  cerebral  haemorrhage,  and 
;vithout  doubt,  if  the  haemorrhage  is  slight  and  is  limited  to  one 
aemisphere,  the  results  will  be  highly  satisfactory,  and  the  operation 
should  be  undertaken.  There  is  often  a  difficulty,  however,  in  making 
mre  that  haemorrhage  exists,  and  in  determining  whether  or  not  the 
laemorrhage  is  bilateral.  This  is  well  indicated  in  Cushing's  cases, 
md  especially  in  Case  3,  where  first  the  one  and  then  the  other 
mrietal  bone  was  turned  down,  and  blood-clot  washed  away  from  each 
Hemisphere. 

I  am  in  entire  agreement  with  those  operators  who  point  out  how 
vvell  the  child  bears  these  operations,  for  in  the  cases  which  I  have 
seen  operated  upon,  or  have  operated  upon  myself,  the  children  were 
ingularly  little  disturbed. 

In  dealing  with  cases  of  cerebral  disturbance  immediately  follow- 
ing parturition,  it  must  not  be  forgotten  that  in  a  considerable  number 
}f  cases  the  disturbances  are  not  produced  by  gross  intracranial 
aaemorrhage.  In  two  cases  which  were  under  my  care  where  there 
ivas  evidently  increased  intracranial  pressure,  and  where  convul- 
sive seizures  appeared  a  few  days  after  delivery,  more  especially 
narked  on  the  one  side,  I  was  disappointed  to  find  when  the  skull  was 
opened  that  there  was  no  haemorrhage  to  speak  of.  In  one  there  was 
i  very  small  blood-clot,  about  the  size  of  a  split  pea,  which  I  could  not 
relieve  was  sufficient  to  cause  the  disturbance.  The  children  in  these 
;wo  cases  were  born  spontaneously  ;  indeed,  the  births  might  almost 
je  termed  precipitate.  In  one  of  the  cases  there  was  no  history  of 
lervous  disturbances  in  the  family,  in  the  other  the  father  and  a 
)aternal  grand-uncle  both  had  infantile  paralytic  affections.  The 
nothers  were  both  particularly  healthy  during  pregnancy.  They  had 
10  disturbances  whatever  and  had  no  albuminuria.  One  of  the 
jhildren  was  very  much  better  after  the  operation — the  convulsions, 
itc,  ceased — but  it  now  presents  nervous  phenomena.  It  is  six  years 
)ld.  Its  mental  development  has  been  very  slow,  and  it  was  nearly 
.wo  years  old  before  it  could  walk.     In  the  other  case  both  parietal 


676  OPERATIVE  MII>WJFKI;Y 

bones  were  turned  down  in  the  hope  that  a  hemorrhage  might  be 
discovered,  but  no  blood-clot  whatever  was  found.  The  child  died 
some  twelve  hours  after  the  operation. 

In  these  cases  where  nervous  phenomena  appear  in  very  early 
infancy  and  childhood,  there  is  a  tendency  to  attach  too  much  impor- 
tance to  the  injuries  at  birth.  It  must  not  be  forgotten  that  in  many 
cases  there  has  been  no  cerebral  haemorrhage.  The  disease  is  tin- 
result  of  hereditary  weakness  and  of  a  toxaemia.  For  example,  in  not 
a  few  of  the  cases  there  has  been  a  history  that  the  mothers  suffered 
from  eclampsia.  I  have  repeatedly  seen  the  children  born  of 
eclamptic  mothers  seized  with  convulsions  shortly  after  their  birth, 
and  in  almost  all  children  born  of  eclamptics  albumen  will  be  found 
in  the  urine.  It  is  quite  probable  also  that  the  poisons  in  the  other 
toxemias,  such  as  pernicious  vomiting,  may  also  have  an  injurious 
effect  upon  the  fine  tissue  of  the  brain  of  the  fotus. 

Last  of  all,  asphyxia,  apart  from  that  produced  by  extreme 
dystocia  and  operative  interference,  very  decidedly  favours  the  con- 
dition, as  can  be  judged  by  the  writings  of  all  who  have  investigated 
this  subject. 

Late  nervous  manifestations,  such  as  Little's1  disease,  etc.,  cannot 
be  considered  here.  The  practical  question  in  connexion  with  these 
cases,  which  show  cerebral  disturbances  shortly  after  delivery,  is — I 
Under  what  circumstances  should  the  skull  be  opened  ?  Certainly, 
if  there  is  extreme  intracranial  pressure  and  blood-stained  cerebro- 
spinal fluid,  it  should  be  done  ;  but  where  there  are  no  such  certain 
signs  of  intracranial  haemorrhage,  it  is  much  more  difficult  to  decide 
when  surgical  interference  is  advisable. 

Facial  Paralysis. — The  most  frequently  injured  nerve  is  the 
seventh  cranial  (facial),  but  happily  the  ultimate  results  are  not  usually 
serious.  From  its  anatomical  situation  one  can  easily  understand 
how  exposed  it  is.  Thus  it  happens  that  the  tip  of  the  blade  of  the 
forceps  frequently  presses  on  the  nerve-trunk  at  its  point  of  exit  from 
the  skull.  This  accident  is  most  likely  to  happen  when  the  grip  is 
not  the  '  ideal,'  and  the  head  is  grasped  more  or  less  obliquely.  On 
account  of  the  obstruction  to  labour  which  deformity  of  the  pelvis  offers 
(flat  rachitic),  facial  paralysis  is  distinctly  more  frequent  in  this  type. 
The  lesion,  as  a  rule,  is  unilateral :  occasionally,  although  extremely 
rarely,  it  may  be  bilateral.  The  prognosis  is  good.  As  a  rule,  the 
paralysis,  which  at  first  is  very  noticeable,  begins  to  improve  within 
a  very  short  time  after  delivery,  and  at  the  end  of  ten  days  is  almost 
entirely  gone.  This  is  the  usual  type.  Another  variety  of  facial 
paralysis  is  of   central  origin.     This  form  is  much  less  commonly 

1  Trans.  Lond.  Obst.  Soc,  vol.  iii.,  p.  '293. 


ACCIDENTS  TO  CHILD  677 

encountered.  It  is  of  a  gradually  deepening  character,  but  usually  if 
the  child  survives  it  also  entirely  disappears. 

'Birth  Paralysis,'  or  Duchenne's  Paralysis. — This  form  of 
paralysis  in  the  new-born  is  especially  associated  with  Duchenne's 
name.  He  described,  in  1872,  four  cases  of  paralysis  of  certain 
muscles  of  the  shoulder  and  arm,  under  the  title  of  '  Paralysies 
obstetricales  infantiles  du  Membre  superieur.'  These  cases  pre- 
sented identical  symptoms,  and  in  each  the  same  muscles  were 
involved  —  viz.,  the  deltoid,  infraspinatus,  biceps,  and  brachialis 
anticus.  In  all  but  one  of  the  cases  the  electrical  reactions  were 
abolished  and  cutaneous  sensation  still  remained.  The  arm  hung 
powerless  by  the  side  and  could  not  be  abducted ;  the  forearm  was 
extended  and  could  not  be  flexed  ;  and  the  hand,  in  consequence  of  the 
inward  rotation  of  the  humerus,  could  not  be  completely  supinated. 
From  the  distribution  of  the  paralysis  Duchenne  came  to  the  conclu- 
sion that  the  lesion  was  one  of  rupture  or  compression  of  nerve  fibres 
in  the  brachial  plexus  before  they  enter  the  main  nerve  trunks  of  the 
arm.  Erb,  in  187-1,  from  his  investigations  on  a  form  of  paralysis  in 
adults  presenting  almost  similar  characters  to  that  previously  reported 
by  Duchenne,  located  the  injury.  This  he  found  to  be  an  injury  of  the 
anterior  primary  divisions  of  the  fifth  and  sixth  cervical  nerves,  where 
they  unite  to  contribute  to  the  brachial  plexus.  Subsequent  researches 
have  proved  this  fact,  as  it  has  been  shown  that  the  motor  nerve  fibres 
in  the  anterior  divisions  of  the  fifth  or  sixth  cervical  nerves  at  their 
point  of  junction  are  those  which  supply  the  muscles  affected. 

Such  being  the  explanation  of  this  form  of  paralysis,  let  us  see  what 
is  its  causation.  The  nerves  involved  are  so  definitely  demarcated  that 
one  must  try  and  find  a  reason  for  their  specific  selection.  However 
the  injury  is  produced,  either  by  compression  or  stretching  of  the  upper 
part  of  the  brachial  plexus,  the  fifth  and  sixth  nerves  have  their  con- 
ductivity destroyed.  Different  opinions  are  held  as  to  the  true  cause. 
Some  say  that  the  nerves  are  injured  by  their  compression  between 
the  clavicle  and  the  transverse  processes  of  the  vertebrae ;  others 
affirm  that  the  nerves  are  damaged  by  compression  between  the  clavicle 
and  the  first  rib. 

Kennedy  of  Glasgow,1  to  whose  writings  I  am  indebted  for  the 
above  remarks,  and  whose  name  is  specially  associated  with  the 
surgical  treatment  of  this  accident,  affirms  '  that  the  chief  factor  in 
producing  the  lesion  is  forcible  depression  of  the  shoulder,  while  the 
head  is  bent  to  the  opposite  side  and  rotated.'  In  this  position 
Kennedy  has  shown  that  the  junction  of  the  fifth  and  sixth  cervical 
nerves  suffers  maximum  tension,  the  lower  cords  being  scarcely  affected 

1  Brit.  Med.  Jour)!.,  1903,  vol.  i.,  p.  298. 


678  OPERATIVE  MIDWIFERY 

at  all.  Harris  and  Lowe1  state  that  only  the  lifth  nerve  is  invol 
and  in  proof  of  this  assertion  show  that  traction  of  the  neck,  as  in 
pulling  to  one  side,  is  more  likely  to  injure  the  more  delicate  lifth 
nerve  than  the  stronger  junction  of  the  sixth.  From  such  an  explana- 
tion it  is  clear  that  this  type  of  injury  is  likely  to  occur  when,  for  some 
reason,  considerable  force  is  required  to  deliver  the  child.  While 
occurring  most  commonly  in  head-first  cases  (on  account  of  their 
frequency),  the  injury  may  follow  any  presentation.  In  breech  pre- 
sentations or  transverse  presentations,  followed  by  version,  the  injury 
results  in  delivering  the  arms  and  after-coming  head.  In  vertex 
presentations  it  results  from  forcibly  pulling  upon  the  head  when 
delivering  the  shoulders. 

The  prognosis  is  variable.  Some  cases  recover  rapidly  :  others 
make  only  a  partial  recovery  after  a  year  or  more  :  many  others  are 
permanently  injured.  In  all  cases  the  opinion  of  a  surgeon  should  be 
taken,  as  operative  interference  offers  most  gratifying  results  in  many 
cases. 

Asphyxia  Neonatorum. 

Much  theorizing  and  speculation  has  been  occasioned  in  the 
attempts  to  find  an  adequate  reason  for  the  genesis  of  the  first  respira- 
tory attempts  of  the  child. 

From  experiments  upon  the  lower  animals,  it  would  appear  that 
the  gradual  accumulation  of  carbonic  acid  in  the  blood  stimulates  the 
respiratory  centre  and  is  the  chief  cause,  although  it  is  likewise  true 
that  peripheral  stimulation  does  independently  excite  respiratory 
action.  Clinically,  this  last  factor  is  well  known.  One  is  quite 
familiar  with  the  sight  of  newdy-born  children  in  a  moderate  degree 
of  asphyxia,  only  made  to  breathe  by  external  stimuli  (slapping,  dash- 
ing cold  water  on  chest,  etc.).  But  we  have  proof  clinically  of  the 
other  factor  also,  for  in  cases  where  the  children  are  rapidly  extracted 
by  Csesarean  section  they  are  frequently  in  a  condition  of  apncea.  In 
these  cases  there  has  been  no  gradual  accumulation  of  carbonic  acid. 

The  application  of  these  foregoing  facts  to  practical  midwifery  is 
easy.  After  the  membranes  rupture  and  labour  proceeds  to  the 
termination  of  the  second  stage,  the  placental  circulation  is  being 
repeatedly  interfered  with  by  the  uterine  contractions;  the  child, 
especially  its  head,  is  being  subjected  to  external  pressure  in  its 
passage  through  the  utero-vaginal  tract,  and  finally  there  is  a  change 
of  environment  from  liquid  medium  at  !)i)°  to  the  air  at  65°.  The 
combination  of  the  accumulated  carbonic  acid  in  the  blood  and  the 

1  Brit.  Med.  Joitrn.,  1903,  vol.  ii.,  p.  1085. 


ACCIDENTS  TO  CHILD  679 

external  stimulus  results  in  a  gasp  or  cry  and  the  establishment  of 
respiration  and  the  pulmonary  circulation. 

The  causes  of  asphyxia  neonatorum  are  numerous,  and  I  purpose 
dividing  them  into  three  main  groups  : 

1.  Traumatism. 

2.  Interference  with  the  placental  circulation. 

3.  Interference  with  pulmonary  circulation. 

1.  Traumatism. — As  examples  of  this  group  we  have — (a)  Badly- 
applied  forceps,  (b)  Undue  prolongation  of  '  moulding  of  head,'  either 
where  the  pelvic  canal  is  narrowed  by  the  presence  of  bony  malforma- 
tions, tumours,  etc.,  or  where  there  is  a  great  disproportion  between 
the  head  and  the  pelvis  because  of  undue  size  of  the  fcetus.  In  this 
group,  called  by  Barnes  'paralytic  asphyxia,'  the  condition  is  pro- 
duced by  compression  or  injury  to  the  brain,  especially  compression 
or  injury  to  the  medulla  oblongata.  Spencer1  showed,  in  his  most 
valuable  paper  on  the  post-mortem  examination  of  newly-born 
children,  that  injuries  to  the  brain  and  its  membranes  are  far  from 
infrequent,  and  that  although  slighter  haemorrhages  are  found  even 
in  spontaneous  deliveries,  these  haemorrhages  are  much  more  frequent 
and  extensive  in  cases  of  dystocia.  In  these  cases  one  finds  meningeal 
effusions,  congestion,  and  small  haemorrhages  into  the  pons  and 
medulla  :  less  frequently  gross  intracranial  haemorrhages.  Thus  the 
cause  of  death  in  these  cases  would  seem  to  be  due  to  direct  and  in- 
direct injury  to  the  brain  and  respiratory  and  cardiac  centres.  The 
fcetus  in  most  of  such  cases  dies  without  ever  making  any  respiratory 
efforts. 

2.  Interference  with  the  Placental  Circulation. — This  interference 
with  the  placental  circulation  may  be  due  to  several  causes  :  (a)  Pre- 
mature separation  of  the  placenta,  as  in  placenta  praevia  or  accidental 
haemorrhage,  (b)  Direct  pressure  on,  or  constriction  of,  the  umbilical 
vessels  by  knots,  twists,  or  prolapse  of  the  cord.  (N.B. — Occasionally 
the  asphyxia  results  when  a  cord  twisted  round  the  neck  of  the  child 
gets  pressed  against  the  symphysis  pubis  while  the  child  is  being  born. 
This  cause  is  often  overlooked,  for  the  accoucheur  has  auscultated  the 
fcetal  heart  and  found  it  quite  satisfactory  before  proceeding  to  deliver 
the  child.)  (c)  In  cases  of  prolonged  labour  after  rupture  of  the 
membranes,  accompanied  by  undue  prolongation  of  the  uterine  contrac- 
tions, thereby  causing  temporary  interferences  of  the  placental  circula- 
tion, {d)  Grave  diseases  of  the  mother,  in  which,  for  various  reasons, 
her  circulation  is  impeded  or  interfered  with — e.g.,  heart  and  lung 
diseases,  anaemia,  haemorrhage,  or  the  moribund  state,     {e)  Poisons 

1  Trans.  Lond.  Obst.  Soc,  1891,  vol.  xxxiii.,  p.  203. 


680  o|'i.l;\TI\  i:  MIDWIFERI 

circulating  in  the  maternal  system — syphilis,  uraemia,  etc  (/)  With 
undilated  or  rigid  cervix,  where  the  child  makes  premature  attempts 
at  respiration,  or  where  the  cervix  is  so  closely  applied  to  its  neck  as 
to  obstruct  the  circulation  altogether. 

In  this  type  of  asphyxia  the  apnosa  of  the  fu-tus  is  usually  pre- 
ceded by  intra-uterine  attempts  at  respiration,  the  result  of  the  accumu- 
lation of  carbonic  acid  in  the  blood.  The  respiratory  centre  in  tin- 
medulla  is  excited,  and  (except  where  the  mouth  of  the  child  is  closely 
applied  to  its  own  body  or  to  the  uterine  wall),  with  the  expansion  of 
the  chest,  meconium,  amniotic  fluid,  and  mucus  are  aspirated.  As  a 
result  of  this,  a  condition  of  grave  venous  congestion  occurs  in  the 
lungs,  and  the  cardiac  action  is  inhibited.  As  the  carbonic  acid 
accumulates,  the  medulla  becomes  more  deeply  poisoned,  and  death  re- 
sults. The  heart  cavities,  especially  on  the  right  side,  are  found  tilled 
with  venous  blood,  and  hemorrhage  occurs  into  the  cranium,  liver, 
spleen,  etc.  This  is  the  commonest  type  of  f<etal  asphyxia,  though, 
happily,  in  the  great  majority  of  cases  the  termination  is  not  fatal. 

3.  Interference  with  the  Fatal  Pulmona/ry  Circulation. — Here  the 
child  is  presumably  born  and  has  independently  breathed  and  lived  a 
separate  existence.  This  is  really  true  asphyxia,  as  we  recognize  it  in 
suffocation,  drowning,  overlying — e.g.,  where  the  child  is  born  with  a 
caul,  or  has  its  mouth  or  nasal  passages  obstructed  by  mucous  or 
maternal  secretions,  or  is  placed  in  bed  with  its  face  downwards  and 
is  too  weak  to  move. 

It  is  customary  to  distinguish  two  forms  of  asphyxia  neonatorum 
— (a)  asphyxia  livida  ;  (b)  asphyxia  pallida.  It  is  very  questionable, 
however,  if  one  should  not  distinguish  an  apncea  pallida,  in  which  the 
respiratory  centre  is  so  injured  that  it  is  really  never  called  into  action. 

Asphyxia  Livida. — In  asphyxia  livida  the  skin  is  dusky  red  or 
purple,  and  the  cutaneous  vessels  are  turgid.  The  umbilical  vessels 
are  likewise  overfilled  with  dark-coloured  blood  and  are  usually 
pulsating  strongly.  The  cardiac  action  is  good  and  not  unduly 
slowed.  Muscular  tonicity  is  evidenced  by  the  fact  that  the  limbs  are 
not  limp,  nor  has  the  sphincter  ani  lost  its  power. 

This  is  practically  the  normal  condition,  if  one  can  so  put  it,  of 
newly-born  children.  Children,  on  the  other  hand,  delivered  rapidly 
by  Cesarean  section  are  of  a  paler  hue,  yet  not  resembling  in  the 
least  the  pallor  of  asphyxia  pallida. 

The  prognosis  in  such  a  simple  case  of  asphyxia  livida  is 
invariably  good.  At  first  the  child  may  not  make  any  attempts  at 
spontaneous  respiration,  but  after  a  brief  period  feeble  respiratory 
efforts  are  observed,  which  are  shortly  followed  by  more  active 
attempts,  and  finally  reach  a  climax  in  a  cry. 


ACCIDENTS  TO  CHILD  681 

The  combination  of  accumulated  carbonic  acid  and  the  cutaneous 
stimulation  of  rubbing,  slapping,  or  dashing  cold  water  on  chest,  etc., 
result  in  the  establishment  of  respiration. 

This,  as  I  have  already  indicated,  is  the  normal  type  of  asphyxia 
neonatorum,  but  a  very  fine  line  of  demarcation  exists  between  this 
type  and  the  next  to  be  considered. 

Asphyxia  Pallida. — Should  the  birth  of  the  child  be  delayed 
further  than  the  stage  of  stimulation,  then  the  respiratory  centre 
becomes  depressed  and  finally  paralyzed  by  the  lack  of  oxygen 
and  the  accumulation  of  carbonic  acid.  The  child  then  passes  by 
degrees — not  rapidly — into  the  state  of  asphyxia  pallida  as  usually 
understood. 

The  most  striking  difference  is  the  colour  of  the  skin,  which  is  of 
a  dirty  white  colour  and  entirely  without  evidence  of  cutaneous  blood- 
supply.  Hardly  less  noteworthy  is  the  absolute  loss  of  muscular 
tone.  The  child  when  delivered  is  limp ;  the  head,  on  account  of  the 
loss  of  muscular  tonicity  in  the  muscles  of  the  back  and  neck,  rolls 
about  unhindered  and  the  jaw  drops.  A  finger  introduced  into  the 
anus  encounters  no  resistance,  as  the  sphincter  ani  has  lost  its  power. 

Cardiac  muscular  paresis  is  also  indicated  in  the  enfeebled,  and 
irregular  cardiac  action,  and  the  lack  of  blood  in  the  skin  and 
umbilical  vessels.  Hence  the  child  presents  just  that  very  appear- 
ance which  one  sees  in  a  person  stricken  down  in  a  faint.  Peculiar 
gasping  attempts  at  respiration  are  made  at  long  intervals.  These  are 
entirely  diaphragmatic  in  character,  unassisted  by  the  ordinary  and 
extraordinary  muscles  of  respiration.  They  are  futile  efforts  ;  very 
little  air  reaches  the  bronchioles. 

Should  success  follow  any  of  the  means  employed  to  resuscitate 
the  child,  the  colour  of  the  skin  changes,  the  cardiac  action  becomes 
slower,  more  forcible,  and  regular,  and  tonicity  returns  to  the  mus- 
cular system. 

In  most  cases  in  which  a  post-mortem  examination  is  made  the 
lungs  are  of  a  dark  red  colour,  heavy,  and  present  numerous  sub- 
pleural  haemorrhages  from  the  increased  blood-pressure  in  the  over- 
filled, delicate,  and  distended  pulmonary  vessels.  If  the  child  has 
made  antenatal  attempts  at  respiration,  liquor  amnii,  meconium,  etc., 
are  found  in  the  air-passages.  The  brain  and  its  membranes  likewise 
participate  in  this  congestion ;  meningeal  effusions  and  oedema, 
especially  over  the  cortex  and  base,  are  common.  Haemorrhages  into 
the  substance  of  the  brain  are  comparatively  rare.  The  right  side  of 
the  heart  has  its  cavities  distended  with  dark  venous  blood,  and 
subpericardial  haemorrhages  are  frequently  noted.  Hemorrhages 
into  the  thoracic  and  abdominal  viscera  are  very  general. 


682  OPERATIVE  MIDWIFERY 

Diagnosis. — As  the  labour  progresses  the  modern  accoucheur. 
instead  of  making  frequent  vaginal  examinations,  now  directs  his 
attention  to  the  mother's  pulse-rate  and  temperature  and  to  the  fcetal 
heart-rate.  As  regards  the  last-mentioned — the  fatal  heart-rate — a 
gradually  and  continually  slowing  heart-rate  is  an  indication  of  the 
gradually  increased  irritation  produced  by  the  carbonic  acid  on  the 
vagus  centre,  which  inhibits  cardiac  action.  Of  course  as  labour  pro- 
gresses the  fcetal  heart-beats  become  slower  during  a  uterine  contrac- 
tion ;  but  if  in  the  intervals  they  regain  their  wonted  rate,  and 
especialby  if  they  do  so  quickly  after  the  uterine  contractions  cease, 
then  there  is  no  need  for  alarm. 

It  is  frequently  observed  that  in  a  case  where  there  has  been 
noted  a  continuously  slowing  heart-rate,  there  is  increased  accentua- 
tion of  the  heart-sounds.     This  is  called  by  some  the  '  vagus  heart." 

In  presentations  other  than  the  breech  the  escape  of  meconium  is 
another  symptom  of  importance.  It  results  from  irritation  of  the 
ganglia  in  the  submucous  tissue  of  the  intestines,  and  consequent 
increased  peristalsis.  Later  there  occurs  a  paralysis  of  the  sphincter. 
It  is  quite  certain  that  meconium  is  not  infrequently  expelled  from 
the  fcetal  bowel  during  pregnancy,  then  it  becomes  mixed  with  the 
liquor  amnii.  That  is  of  no  consequence.  It  is  the  expulsion  of 
meconium  in  quantity  after  a  labour  has  been  in  progress  for  some 
time  that  leads  one  to  be  anxious  about  the  child.  I  need  not  remind 
my  readers  that  the  escape  of  meconium  is  a  natural  feature  of 
breech  presentations. 

Very  frequently  immediately  before  its  death  the  child  becomes 
very  restless.  The  child  also  may  make  respiratory  efforts,  and  if  air 
happens  to  be  carried  into  the  uterus — as,  for  example,  by  the 
operator's  hand — then  the  child  may  actually  draw  in  this  air,  and 
the  uterine  cry  ('  vagitus  uterinus  ')  may  be  heard.  I  heard  this  very 
distinctly  in  a  case  in  which  I  introduced  my  hand  into  the  uterus  to 
perform  version. 

Prognosis. — Except  in  asphyxia  livida,  which  in  its  mildest  form 
is  practically  the  normal  condition  of  the  child  at  birth,  the  prognosis 
is  far  from  good. 

Pulmonary  and  cerebral  extravasations  of  blood  kill  a  large  number, 
and  later  pneumonia  from  inspired  material  carries  off  not  a  few.  Even 
amongst  those  which  are  resuscitated  a  large  proportion  die  within  a 
few  days.  Indeed,  if  resuscitation  has  been  extremely  difficult  and 
has  only  succeeded  after  an  hour  or  more,  the  mortality  is  very  high 
indeed. 

Treatment. — The  treatment  of  this  condition  varies  according  to 
the  degree  of  asphyxia.     In  the  simple  cases  of  suspended  animation 


ACCIDENTS  TO  CHILD 


683 


following  delivery  all  that  is  required,  as  a  rule,  to  excite  respiratory 
efforts  is  to  apply  cutaneous  stimulation  by  smartly  slapping  the 
child's  buttocks,  dashing  cold  water  on  its  chest,  and  rubbing  the 
child  with  brandy.  If  the  child  is  extremely  livid,  it  is  well  to  allow 
a  few  drops  of  blood  to  escape  from  the  umbilical  cord. 

If  these  simple  procedures  are  not  successful,  the  child  should  be 
seized  by  the  feet  and  held  head  downwards  (Fig.  297),  so  that  any 


Fig.  297. — Clearing  the  Air-Passages  of  the  Child  at  Birth. 

mucus  or  liquor  amnii  may  be  dislodged  from  the  upper  air-passages. 
At  the  same  time  the  child's  chest  should  be  gently  compressed.  If 
there  is  difficulty  in  clearing  the  air-passages,  a  gum-elastic  catheter 
or  insufflator  should  be  passed  into  the  trachea,  and  mucus,  etc., 
removed  by  suction.  Should  such  treatment  fail  and  the  child 
gradually  tend  to  pass  into  the  condition  of  asphyxia  pallida,  with 
slowly  and  feebly  beating  heart,  then  one  must  resort  to  other 
methods. 


684  OPERATIVE  MIDWIFERY 

From  what  has  been  already  said  regarding  asphyxia  pallida, 
where  one  has  to  deal  with  a  limp  child,  very  cold,  and  almost  pulse- 
less, it  is  self-evident  that  heat  must  be  applied  to  the  child's  body. 
Heat  is  best  applied  by  immersing  the  child  in  hot  water.  Immersed 
in  the  warm  water  and  with  its  head  supported,  artificial  respiration 
should  be  carried  out  by  alternately  compressing  and  relaxing  the 
chest.  These  movements  are  made  about  ten  or  twelve  times  per 
minute.  At  this  stage  rhythmic  traction  of  the  tongue  will  be  found 
very  useful.  It  is  an  old  method  of  rerlexly  irritating  the  respiratory 
centre,  and  will  usually  succeed  in  establishing  respiratory  efforts. 
If  it  fails,  the  child  is  in  extreme  danger. 

Personally,  I  am  not  in  favour  of  insufflation  of  the  lungs,  for  the 
air  introduced,  unless  a  mechanical  insufflator  is  employed,  contains 
a  very  large  proportion  of  carbonic  acid.  Besides,  there  is  very  con- 
siderable danger  of  rupturing  the  finer  air-vesicles.  If  it  is  deemed 
advisable  to  employ  insufflation,  it  may  be  carried  out  by  the 
accoucheur  applying  his  own  lips  to  the  lips  of  the  child,  with  a  thin 
piece  of  gauze  intervening  ;  but  this  direct  method  is  not  sanitary,  and 
the  greater  part  of  the  air  forced  into  the  thorax  passes  into  the 
stomach.  It  is,  therefore,  better  to  employ  the  indirect  method  and 
pass  a  gum-elastic  catheter  into  the  trachea.  The  nose  and  mouth  of 
the  child  are  then  closed,  and  the  accoucheur  forces  a  certain  amount 
of  air  into  the  child's  lungs.  This  forcing  of  the  air  into  the  child's 
lungs  must  be  done  very  cautiously.  The  accoucheur  must  take  care 
that  the  tube  is  really  in  the  trachea,  and  not  in  the  (esophagus,  and  that 
the  air  is  not  forced  too  strongly  into  the  air-passages  of  the  child. 

The  following  methods  of  artificial  respiration  may  be  employed  in 
the  case  of  the  new-born  child  : 

Schultze's  Method.— The  child  is  held  as  indicated  in  the  illustra- 
tion. The  thumbs  lie  over  the  child's  shoulders,  clavicles,  and  front 
of  the  chest ;  the  fore  and  middle  fingers  are  laid  flat  against  the 
posterior  and  lateral  walls  of  the  thorax,  while  the  ring  and  little 
fingers  support  the  head. 

The  accoucheur  stands  with  the  child  grasped  as  described  and 
hanging  between  his  legs  (Fig.  2!)8).  He  then  swings  the  child  so 
that  the  trunk  falls  over  into  the  position  indicated  in  right-hand 
figure  :  at  the  same  time  the  chest  is  compressed.  This  movement 
simulates  expiration.  After  pausing  a  second  or  two,  he  then  swings 
the  child  back  into  the  first  position.  That  movement  simulates 
inspiration.  The  two  movements  should  be  carried  out  about  the  rate 
of  eight  to  twelve  times  per  minute,  and  should  not  be  continued  for 
more  than  two  minutes.  The  child  should  then  be  put  back  into  the 
hot  bath.     The  swinging  is  repeated  as  deemed  advisable. 


ACCIDENTS  TO  CHILD 


085 


Byrd's  Method. — This  method  is  carried  out  by  holding  the  child 
in  the  two  hands,  as  indicated  in  the  illustration  (Fig.  299).  By 
extending  the  back  and  allowing  the  head  to  become  extended, 
expansion  of  the  chest-wall  is  brought  about ;  while  by  approximating 
the  two  ends  of  the  trunk  compression  of  the  chest  is  produced 
(Fig.  299).  These  inspiratory  and  expiratory  movements  are  carried 
out  about  ten  times  per  minute.  This  method  may  be  employed 
when  the  child  is  in  a  warm  bath.     (N.B. — If  the  child  is  not  in  a 


Fig.  298.— Schultze's  Method  of  Performing  Artificial  Respiration. 

bath,  it  should  be  turned  face  downwards  at  the  end  of  expiration,  so 
that  any  mucus  may  be  dislodged.) 

Sylvester's  Method. — In  this  method  the  child  is  placed  on  its 
back,  with  the  shoulders  slightly  elevated  and  the  head  hanging  over 
the  pillow.  In  order  to  carry  out  the  manoeuvres  successfully,  the 
legs  must  be  fixed  by  an  assistant,  and  the  tongue  must  be  pulled 
forward  with  a  piece  of  gauze  to  ensure  the  free  entrance  of  air.  The 
child's  arms  are  then  grasped  and  pressed  against  the  chest-wall  : 
expiration  is  thus  imitated.  The  arms  are  then  everted  and  carried 
upwards  above  the  head  :  inspiration  is  thus  imitated. 


686 


OPERATIVE  MEDWIFER1 


Marshall  Hall's  Method.— The  child  is  laid  on  its  back,  with  the 
head  hanging  over  the  knees  of  the  doctor  or  nurse.  It  is  then  seized 
l>y  an  arm  and  thigh  and  rolled  over  until  the  chest  looks  a  little 
downwards  ;  at  the  same  time  the  chest  is  compressed.  The  child  is 
then  rolled  back  to  its  original  position.  The  movements  are  repeated 
twelve  times  per  minute.  In  this  method  air  is  forced  out  of  the 
chest  when  the  child  is  rolled  on  to  its  side,  and  inspired  when  it  is 
rolled  on  to  its  back. 

Personally,  I  do  not  favour  the  employment  of  Schultze's  method 
of  artificial  respiration.  I  am  well  aware  that  many  obstetricians 
approve  of  it,  and  I  have  not  the  least  doubt  that  air  is  drawn  in  and 


Fie  299. — Byrd's  Method  of  Performing  Artificial  Respiration. 


forced  out  very  effectively  by  means  of  it.  There  is  no  doubt  also 
that  the  heart  is  mechanically  stimulated  by  it.  In  severe  cases  of 
asphyxia  pallida,  however,  it  has  always  appeared  to  me  too  violent. 
"We  have  seen  in  those  cases  that  hemorrhages  into  the  brain  and 
abdominal  viscera  are  very  common ;  surely,  therefore,  violent 
mechanical  movements  are  undesirable,  as  they  will  tend  to  increase 
the  haemorrhages  already  present.  In  the  slighter  forms  of  asphyxia 
it  is  quite  unnecessary.  It  has  been  my  custom,  therefore,  to  remove 
all  mucus  from  the  air-passages,  immerse  the  child  in  warm  water, 
and  employ  rhythmic  traction  of  the  tongue  and  compression  of  the 
chest.  I  believe  that  by  such  quiet  methods  better  results  will 
be  obtained  than  by  the  violent  movements  employed  in  Schultze's 
manreuvres. 


APPENDIX 

MEASUREMENT   OF   PELVIC   DIAMETERS  BY  THE  ROENTGEN 

RAYS 

By  J.  K.  RIDDELL,  L.R.C.P.  &  S.(Edix.),  L.F.P.S.(Glas.), 
Medical  Electrician,  Royal  Infirmary,  Glasgow. 

The  main  difficulties  to  the  accurate  measurement  of  the  brim  of  the  pelvis 
by  means  of  the  Roentgen  rays  are  : 

1.  The  picture  is  made  by  a  shadow  of  the  object. 

2.  The  plane  of  the  pelvic  brim  and  the  surface  of  the  plate  on  which 
the  shadow  is  cast  are  not  parallel,  but  lie  at  a  certain  angle  to 
each  other. 

3.  The  plate  cannot  be  got  close  to  the  brim,  nor  can  it  be  always  placed 
at  the  same  distance  from  it. 

Of  the  various  methods  employed,  none  is  more  accurate  and  simple  than 
that  used  by  us — namely,  to  make  a  radiogram  of  the  inlet,  under  certain 
definite  conditions  and  eliminate  the  error  by  calculation.  In  applying  it, 
the  following  facts  have  to  be  borne  in  mind  : 

1.  A  plate  can  always  be  so  placed  as  to  rest  on  the  most  posterior  part 

of  the  sacrum  and  on  the  tuberosities  of  the  ischium  at  the  same 
time. 

2.  The  plane  of  this  plate  will  be  at  a  certain  angle  with  that  of  the 

pelvic  inlet,  and  this  angle  will  be  nearly  the  same  in  all  cases. 

3.  The  distance  between  the  plate  so  placed  and  the  centre  of  the  plane 

of  the  pelvic  brim  is  about  3f  inches,  and  never  exceeds  ih  inches. 

Technique. 

Place  the  patient  face  downwards  on  a  canvas-topped  couch,  with  the 
tube  underneath  it  in  a  movable  carrier.  Place  a  small  air  bladder  between 
the  patient's  abdomen  and  the  couch,  just  above  the  symphysis  pubis.  Place 
the  screen  on  the  patient's  back,  darken  the  room,  and  excite  the  tube.  The 
outline  of  the  pelvic  brim  will  now  be  visible,  and  the  tube  can  be  moved 

687 


OPERATIVE  M1I>\\11  Kl;Y 

into  such  a  position  that  the  normal  ray  falls  perpendicularly  on  the  plane 
of  the  inlet.  Thai  the  tube  is  in  the  correct  position  is  judged  by  the 
appearance  on  the  screen,  and,  more  exactly,  by  arranging  that  the  normal 
ray  falls  practically  vertically  on  the  plate  when  placed  in  position.  The 
tube  is  brought  to  a  point  21  inches  distant  from  the  screen  ;  a  plate  in  its 
<laik  bag  is  now  placed  resting  on  the  ischial  tuberosities  and  sacrum,  and  a 
skiagram  is  made. 

To  find  the  correct  position  and  direction  of  the  tube  easily,  we  have  a 
flat  piece  of  wood  measuring  about  6  inches  by  1  inches  ;  from  the  centre  of 
the  longer  edge  of  this  a  rod  juts  out  just  long  enough  to  lie  free  of  the 
couch  when  the  piece  of  wood  is  placed  on  the  plate  (about  1  I  inches).  To 
the  free  end  of  this  a  second  rod,  exactly  24  inches  in  length,  is  attached  at 
light  angles  to  it,  and  vertical  to  the  plane  of  the  piece  of  wood.  The  end 
of  this  second  rod  is  in  line  with  the  spot  at  which  the  anticathode  must  lie, 
and  the  rod  points  the  direction  of  the  normal  ray. 

To  secure  that  the  normal  ray  falls  perpendicularly  to  the  plate,  and  that 
it  passes  through  the  centre  of  the  pelvic  inlet,  a  small  metal  rod,  J,  inch  in 
diameter  and  H  inches  long,  is  attached  vertically  to  the  centre  of  a  thin 
disc  of  vulcanite.  The  disc  is  I  inch  in  diameter.  It  is  attached  with 
sticking  plaster  to  the  glass  of  the  tube  opposite  the  anticathode,  so  that  the 
length  of  rod  lies  in  the  normal  ray.  A  small  metal  disc  is  attached  by 
sticking  plaster  to  the  patient's  back  in  the  middle  line  |  inch  from  the 
tip  of  the  coccyx,  this  being  the  spot  found  to  correspond  with  the  centre  of 
the  inlet.  The  patient  is  now  examined,  and  the  metal  rod  is  seen  as  a 
round  spot  when  the  tube  is  properly  directed,  otherwise  it  appears  more  or 
less  elongated.  The  tube  is  in  proper  position  when  the  spot  represent- 
ing the  metal  rod  is  covered  with  the  shadow  made  by  the  disc  on  the 
patient's  back. 

The  radiogram  thus  obtained  differs  from  the  actual  pelvis  in  two  ways  j 
It  is  enlarged  generally  on  account  of  the  rays  producing  it  being  divergent, 
and  the  antero-posterior  diameter  is  slightly  distorted  because  the  plate  and 
the  plane  of  the  pelvic  brim  are  not  parallel.  As  the  angle  between  them 
is  small  the  distortion  may  be  discounted. 

The  error  due  to  enlargement  is  to  be  corrected  by  multiplying  the 
diameter  of  the  shadow  of  the  pelvis  by  0-84,  and  adding  0-16  inch.  This 
formula  is  arrived  at  by  experiment. 

A  dried  pelvis,  slightly  larger  than  the  average,  was  taken,  and  a  radio- 
gram made  under  the  conditions  given  above — namely,  the  plate  was  made 
to  rest  on  the  most  posterior  part  of  the  sacrum  and  on  the  ischial  tuberosities, 
allowance  being  made  for  the  thickness  of  the  gluteal  muscles.  The  tube 
was  placed  24  inches  distant,  the  normal  ray  falling  through  the  pelvis 
vertically  on  the  plate.  The  brim  was  found  to  lie  practically  parallel  with 
the  plate  and  3-75  inches  distant  from  it.  The  antero-posterior  diameter  of 
the  actual  pelvis  was  4%37  inches,  while  that  on  the  skiagram  was  5*18  inches  : 
thus  5-18  x  0-84  =  4-35  inches.     This  is  practically  exact  where  the  shadow 


APPENDIX  689 

ippens  to  measure  5-18  inches  and  the  object  casting  it  is  3*75  inches  from 
ie  plate.  Unfortunately  the  distance  between  the  plane  of  the  pelvic  inlet 
id  the  plate  varies,  and  cannot  be  accurately  determined.  When  it  is  less 
lan  the  standard  given  above,  the  application  of  the  rule  will  give  something 
ss  than  the  true  diameter.  It  is  therefore  necessary  to  suppose  an  extreme 
ise  and  calculate  the  error  produced. 

Taking  as  an  extreme  case  one  in  which  the  distance  between  the  plane 

the  inlet  and  the  plate  measures  2*75  inches,  we  find  that  on  applying  the 
lie  the  diameter  obtained  is  0-33  inch  less  than  it  should  be.  If,  therefore, 
e  take  half  that  distance — namely,  0*16  inch — and  add  it  to  the  result  in 
'ery  case,  we  shall  overstate  the  true  length  by  that  distance  (0-16  inch)  in 
ses  where  the  pelvis  is  actually  as  large  as  the  standard,  and  understate  it 
here  it  is  as  small  as  the  extreme  case  supposed.  The  error  in  all  cases 
stween  these  extremes  will  be  something  less  than  0-16  inch. 

We  have  proved  this  actually  to  be  the  case  by  experiment  on  the  dead 
bject ;  and  in  a  number  of  cases,  under  the  care  of  Dr.  Munro  Kerr,  we 
ive  found  our  measurements  corroborated  by  the  usual  clinical  ones  made 
7  him. 

This  method  has  in  its  favour  its  great  simplicity,  and  the  objections  to 
can  be  equally  urged  against  the  other  methods.     These  are  : 

1.  The  inability  exactly  to  fix  the  distance  between  the  centre  of  the 

plane  of  the  inlet  and  the  plate. 

2.  The  uncertainty  as  to  the  exact  angle  between  these. 

3.  The  inability  to  secure  that  the  normal  ray  falls  quite  perpendicularly 

on  the  plane  of  the  inlet. 

In  conclusion :  Measure  the  antero-posterior  diameter  of  the  radiogram 
ken  under  the  above  conditions ;  multiply  that  measurement  by  084  and 
id  0*16  inch,  and  the  result  will  be  the  correct  pelvic  measurement  to 
ithin  I-  inch. 


44 


INDEX 


ABDOMEN,    foetal,    enlarged,    cause   of   dys- 
tocia, 10b' 

pendulous,  cause  of  dystocia,  288 

cause  of  rupture  of  vaginal  vault, 

629 
in  contracted  pelvis,  176 
Abdominal    fixation    of    uterus,    cause    of 
dystocia,  291 

pain  in  extra-uterine  pregnancy,  555 

palpation   (see   Palpation,   abdominal), 
15 

pregnancy,  547 

section.     See  Laparotomy 
Abortion,  517 

complete,  522 

criminal,  519 

curettage  in,  529 

diagnosis  from  extra-uterine  pregnancy, 
561 

diagnosis  of,  520 

ergot  in  threatened,  526 

etiology  of,  518 

frequency  of,  517 

habitual,  519 

in  retroflexion  of  gravid  uterus,  273 

incomplete,  522 

indications  for  induction  of,  436 

induction  of,  453 

missed,  524 

plugging  in,  528 

prophylaxis,  525 

repeated,  519 

rupture  of  vagina  in  removing,  527 

septic,  530 

symptoms,  520 

threatened,  521 

treatment  of,  525 

tubal,  538 

varieties,  521 
Abscess  of  Bartholin's  gland,  cause  of  in- 
fection, 260 
Accidental  haemorrhage,  594 

accouchement  force  for,  604 

apparent,  596 

Cesarean  section  for,  604 

concealed,  598 

diagnosis  of,  595 

etiology,  594 

plugging  in,  601 


Accidental  haemorrhage,  prognosis  in.  I     • 

rupture  of  membranes  in,  603 

treatment,  600 

varieties  of,  596 
Accidents,  cause  of  abortion,  519 

to  child.  666 

to  mother,  616,  655 
Accouchement  force,  456 

dilator,  hydrostatic,  461 

expanding  metal  (Bossi),  463 

extraction  of  child,  477 

incisions  of  cervix,  468 

indications  for,  456 

manual  dilatation  in,  459 

methods  of  operating,  453 

metreurynter  in,  461 

tents,  expanding,  in,  460 
Acute  diseases  in  pregnancy,   induction  "f 

labour  for,  436 
Adhesions  after  Cesarean  section,  429 

amniotic  bands,  141 
Adipocere  formation  in  ectopic  Pectus,  565 
After-coming  head,  craniotomy,  197 

extraction  of,  69 

forceps  to,  70.  360 

moulding  of,  in  contracted  pelvis,  193 
Age  of  foetus,  difficulty  of  calculating,  440 
Air,  embolism,  663 
Albuminuria,  cause  of  abortion,  519 
accidental  ha-niorrhage,  595 

induction  of  labour  for,  438,  440 
Albuminuric  retinitis,   induction   of  labour 

for,  438 
Alcohol  as  antiseptic,  309 
Amenorrhrea,     significance     of,    in     extra- 
uterine pregnancy,  556 
Amnion,     rupture    of,    chorion     remaining 

intact,  150 
Amniotic  adhesions.  1 52 
Ampullar  pregnancy,  •"•'!s 
Amputation  of  leg,  effect  upon  pelvis,  175 
Anaemia,  pernicious,  induction  of  labour  in, 

438 
Anaesthesia,  advantages  in  performing  ver- 
sion, 319,  689 

effect  on  parturition,  31  I 

general,  314 

posl  partum  haemorrhage  followii  s 
608 


>;w 


INDEX 


(51)1 


Anaesthesia,  spinal,  315 
Angular  pregnancy,  562 

Annular  detachment  of  cervix,  202 
Anteflexion,  cause  of  dystocia  after  vaginal 
fixation,  290 
cause  of  dystocia  after  ventral  fixation, 

292 
in  contracted  pelvis,  177 
of  gravid  uterus,  287 
Ante-partum  hemorrhage.  See  Hemorrhage 
Vnteversion.     See  Anteflexion 
^.nus,  laceration  of  sphincter,  646 

repair  of  sphincter,  653 
Appendicitis  during  pregnancy  and  labour, 
262 
simulating  extra-uterine  pregnancy,  552, 
560 
Arm,  diagnosis  from  leg,  90 
diagnosis  of  particular,  91 
dorsal    displacement   of,   in   head   pre- 
sentations, 48 
in  breech  presentations,  67 
fracture  of,  672 

prolapse  of,  in  bead  presentations,  47 
in  transverse  presentations,  89,  323 
Artificial  respiration.     See  Asphyxia  neona- 
torum, 684 
iscites  of  foetus,  dystocia  from,  108 
ispbyxia  neonatorum,  678 
etiology  of,  679 
haemorrhages  in  fojtus  associated  with, 

673,  679 
livida,  680 
pallida,  681 
prognosis,  682 
treatment,  682 
;  .ssimilation  pelvis,  159 

stringents  in  post-partum  hemorrhage,  613 
i  tony  of  uterus.     See  Uterine  inertia 
tresia  of  cervix,  cause  of  dystocia,  204 
of  vagina,  206 
of  vulva,  206 
ttitude  of  foetus,  15 

uscultation,  diagnosis  of  presentation  and 
position  of  child  from,  24 
foetal  heart,  23  " 

importance  of,  during  labour,  4,  23 
in  multiple  pregnancy,  114 
uterine  souffle,  23 
xis  of  pelvis,  variations  in,  337 

traction  forceps.     See  Forceps,  333 
yres'  method   of  performing  symphysio- 
tomy, 392 

ickward    displacement   of    gravid   uterus 
(see  Retroflexion  of  gravid  uterus),  265 
icteriology  of  vaginal  secretion,  312 
ig    of    membranes    confused   with   caput 
succedaneum,  macerated  fretal  bead, 
cedematous  scrotum,  cystocele,  150 
premature  rupture  of,  148 
illottement  of  head  in  diagnosis  of  breech 
presentations,  50 
mdl's  ring.     See  Retraction  ring 
imes'  hydrostatic  dilator,  462 


Bartholin's  glands,  abscess  of,  complicating 

labour,  260 
Basilyst,  494 

Baudelocque's  omphalotribe,  493 

diameter,  measurement  of,  178 
Bichloride    and    biniodide  of   mercury  as 

antiseptics,  308 
Bicornuate  uterus,  cause  of  dystocia,  295 
pregnancy  in,  294 
rupture  of,  300 
Binder,     abdominal,     in     correcting     mal- 
presentations,  95,  328 
in  pendulous  abdomen,  288 
in  plugging  for  accidental  haemor- 
rhage, 603 
Biparietal  obliquity,  164 
Bipolar  version,  329 

in  placenta  previa,  589 
Bladder,  ectopia  of,  in  split  pelvis,  159 

irritation  of,  in  anteflexion  of  uterus, 
287 
in  ectopic  pregnancy,  558 
in  short  umbilical  cord,  145 
rupture  of,  in  backward  displacement 
of  gravid  uterus,  272 
in  rupture  of  uterus,  628 
stone  in,  256 

tumour  of,  complicating  labour,  256 
Blood,  diseases  of,  induction  of  labour  for, 
438 
mole,  524 
Blunt  hook,  492 
Bougie  for  induction  of  premature  labour 

(Krause's  method),  448 
Brain,  injuries  to  fcetal,  673 
Braun's  decapitating  hook,  502 

cranioclast,  492 
Braxton    Hicks'    method    of    version    (see 

Bipolar  version),  329 
Breech  presentations,  50 

arms,  difficulty  in  bringing  down,  62 
auscultation  in,  24 

cephalic  version  during  pregnancy,  85 
complicated  by  contracted  pelvis,  51 
extended  legs,  78 
fillet  in,  81 

foot,  bringing  down,  52 
forceps  in,  83 

head,  after-coming,  extraction  of,  69 
impacted,  extraction  of,  78 
in  hydrocephalus,  100 
liberation  of  arms  in,  62 
nuchal  or  dorsal  displacement  of  arm,  6S 
treatment  of,  during  labour,  50 
during  pregnancy,  85 
Broad  ligament,  hematoma,  209-21 1 

simulating  accidental  haemorrhage,  598 

pregnancy,  541 
rupture  of  uterus,  617 
Brow  presentations,  43 

couversion  of,  into  face  or  vertex,  39 
frequency  of,  43 
moulding  of  head  in,  45 
prognosis  in,  44 
symphysiotomy  in,  46,  375 


692 


OPERATIVE  MlDWIFEllY 


presentations,  treatment  ol 
•  >n  in.  ir» 
Byrd'a  method  of  resnsoitation,  I 

■  otion  for  accidental  haemorrhage, 
604 

conservative,  410 

contra-indications,  106 

following  vagino-fixation,  291 
rentro-fixation,  292 

For  carcinoma  of  cervix,  21  7 
of  rectum,  258 

for  contracted  pelvis,  192,  401 

for  eclampsia,  406 

bypertrophied  cervix,  201 

for  myasthenia  gravis,  107 

for  myoma  of  uterus,  252 

for  ovarian  tumour,  229 

for  placenta  previa,  407,  593 

for  vaginal  cicatrices.  207 

hysterectomy  after,  417 

indications  for,  404 

mortality  from,  430 

on  the  dead  or  dying,   133 

Porro's  operation,  417 

post-mortem.  433 

preparation  for,  407 

prognosis  of,  430 

repeated,  429 

results  to  mother  and  child,  430 

sterilization  of  patients  after.  427 

symphysiotomy  contrasted,  379,  403 

technique  of,  410 

time  for  operating,  408 

vaginal  (see  Vaginal  Cesarean  section), 
470 
Calcification  of  fcetus  in  extra-uterine  preg- 
nancy, 565 
Cancer.     See  Carcinoma 
Caput  succedaneum,  cause  of,  666 

diagnosis  from  bag  of  membranes,  150 
Carbolic  acid  as  antiseptic,  308 
Carcinoma    of   cervix,    complicating    preg- 
nancy and  labour,  214 

proportion  of  operable  cases,  216 

treatment,  219 
Carcinoma  of   rectum    complicating  preg- 
nancy and  labour,  257 
Cardiac  disease.    See  Heart  disease,  maternal 
Carneous  mole,  524 
Catgut,  sterilization  of,  306 
Catheterization  before  operation,  314,  345 

danger  of  infection,  314 
Caul,  danger  to  child  born  with,  680 
'  lephalic  version,  316 

in  breech  presentations,  85 

methods  of  performing,  325 
Cephalometer,  187 
<  lephaletribe,  493 

combined  cranioclast  and  cephalotribe, 
494 
Ceivix,  acute  (edema  of,  203 

amputation  of,  for  hypertrophy,  201 
for  carcinoma  of  cervix,  218 

annular  detachment  of,  202 


( !ervix,  atresia  ol   - 

carcinoma  ol   Bee  I  iarcinoma  ol 

21  I 

changes  in,  during  labour,  ''>2l 
dilatation  ol    see  Dilatation  "i  cervix), 

156 
hypertrophy  of,   complicating   labour, 

201 
incision  of   see  Vaginal  Caesarean  sec- 

tion 
laceration  of,  6  !■! 
oedema  ol 

rigidity  ol    see  Rigidity  of  cervi 
stenosis  of  204 
( !hild,  relative  claims  of  mother  and  child,  2 
Chioid  (thoracopagons   monster,  128 
Chloroform  in  labour  (see  Anaesthesia  ,  314 
Chorea,  induction  of  labour  for. 
Chorion,  disease  of  see  Hydatidi  form  n 
532 
retention  of,  514 
Chorion-epithelioma,  534 
Circular  sinus  of  placenta,  rupture  of,  147 
Clavicle,  fracture  of,  072 
Cleidotomy,  505 

Cocaine  in  spinal  anaesthesia,  315 
Cohen's  method  of  inducing  labour,   152 
Collapse  following   haemorrhage,   treatment 

of,  613 
Colpeurynter.     See  Metreurynter 
Colporrhexis,  629 
Concealed     haemorrhage     (see     Accidental 

haemorrhage  .  598 
Conglutiuatio  orificii  externi,  204 
Conjugate  diameter  of  1  irim  (Conjugata 
180 
Baudelocque's,  178 
diagonal  (oblique  conjugate),  183 
external,  178 
measurements  of,  180 
of  outlet,  179 
tnie,  180 
Constrictor  vaginae,  importance  of  pic—  i  v- 

iug,  650 
Contracted  pelvis,  Ca-sarean  section  in 
193,  404 
causes  of.  153 
classification  of,  154 
craniotomy  in,  480 
diagnosis  of,  177 
forceps  in,  194,  363 
induction  of  premature  labour  for.  199 

442 
mechanism   of   labour  in    flat    pelvis. 
164 
in  generally  contracted  pelvis,  155 
pelvimetry  in,  17'.' 
prognosis  of  labour  in.  189 
size  of  foetus  in,  192 
spontaneous  delivery  in,  191 
symphysiotomy  in,  193,  375 
treatment   of    labour   complicate!    hv, 

189 
X  rays  in  diagnosis  of,  181.    See  Appen- 
dix 


INDEX 


61)3 


Contraction,  uterine,  5 

definition  of  uterine,  610 

hour-glass  uterine,  14 

in  dystocia,  due  to  contracted  pelvis, 
193 

in  threatened  rupture  of  uterus,  633 

irregular  uterine,  13 

tetanic,  13,  633 
Convulsions.     See  Eclampsia 

of  new-born  child,  676 
Cord.     See  Umbilical  cord 
Cornual  pregnancy,  574 
Corrosive  sublimate  and  biniodide  of  mercury 

as  antiseptics,  309 
Cranioclast,  492 
Craniotomy,  478 

after-coming  head.  497 

in  double  monsters,  127 

in  hydrocephalus,  102,  479 

in  mento-posterior  face   presentations 
43,  360 

in  threatened  rupture  of  uterus,  634 

indications  for,  479 

limitations  in  contracted  pelvis,  480 

living  child,  405,  479 

prognosis  of,  4S2 

technique  of,  483 
Crede's  method  of  expressing  placenta,  513 

rupture  of  uterus  from,  626 
Criminal  abortion,  519 
Crotchet,  492 
Curettage  in  abortion,  529 

diagnostic  purposes  in  ectopic  pregnancy, 
563 
Cystitis  from  catheterization,  314 
Cystocele,  complicating  labour,  289 

mistaken  for  membranes,  150 
Cysts  of  ovary  (see  Ovarian  tumour  causing 
dystocia),  222 

of  vagiua  and  vulva,  causing  dystocia, 
208 

Death  of  fcetus  during  pregnancy,  440 

repeated   induction  of  labour  for, 
441 
of  mother  during  labour,  661 
Decapitation,  500 

in  locked  twins,  120 
in  transverse  presentations,  96,  501 
Decapitating  instruments,  502 
Decidua  in  ovary  in  ovarian  pregnancy,  544 
in  tube  in  tubal  pregnancy,  538 
retention  of,  in  abortion,  522 
shedding   of,   a  sign   of  ectopic   preg- 
nancy, 550,  557 
uterine,  in  ectopic  pregnancy,  549 
Deciduoma  malignum  (see  Chorion-epithe- 
lioma), 534 
Deformed  pelvis.     See  Contracted  pelvis 
Dermoid    cysts    of   ovary.       See    Ovarian 

tumours,  222 
Diameters  of  pelvis,  measurements  of,  178 
of    fcetal    head,    alterations    result    of 
compression,  194,  343 
Dicephalous  monster,  127 


Dilatation  of  cervix,  artificial,  156 
manual,  459 
with  forceps,  34  1 
with  metal  dilators,  463 
with  metreurynter,  461 
with  tents,  460 
Disinfection  of  abdominal  wall  before  lapar- 
otomy, 313 
of  hands,  307 
of  instruments,  etc.,  304 
of  vagina,  312 
of  vulva,  311 
Displacement  of  arms  in  head  presentations, 
46 
of  uterus  (see  Uterus,  displacements  of), 
265 
Dolichocephalic  head,  cause  of  face  presen- 
tation, 35 
Double  monsters,  dystocia  from,  122 
Double  uterus  and  vagina,  294 
Douche,    intra -uterine,     for     post-partuni 
haemorrhage,  610 
for      retained      membranes      and 

placenta,  510,  530 
routine  post-partum,  313 
vaginal,  lie  fore  labour,  312 

before  Cesarean  section,  408 
Douglas'  cul-de-sac,  drainage  through,  573 
incising,  in  ectopic  pregnancy,  573 
perforation  of,  in  expressing  ovum  in 
abortion,  527 
Drainage,  abdominal,  disadvantages  of,  567 
vaginal,    in    extra-uterine    pregnancy, 
570,  573 
in  rupture  of  uterus,  641,  643,  645 
Dropsy,  general  fcetal,  98 
Dry  labour,  148 

Duchenne's  paralysis  (birth  paralysis),  677 
Dwarf  pelvis,  155 

Dyspncea   during  pregnancy,   induction   of 
labour  for,  437,  438,  440 
after  delivery,  662 
Dystocia,  classification  of,  3 
definition  of,  1 

result  of  different  abnormal  conditions 
of  forces,  fcetus,  and  parturient  canal. 
See  Contents 
Dysuria  in  extra-uterine   pregnancy,   276, 
558,  572 
from  retrodisplaced  gravid  uterus,  270 

Ecarteur  of  Tarnier,  464 
Eclampsia,  accouchement  force  in,  457 
bleeding  in,  405 
Cxesarean  section  in,  406 
saline  infusion  in,  405 
Ectopic     pregnancy.       See     Extra  -  uterine 

pregnancy,  537 
Embolism,  air,  663 

pulmonary,  immediately  after  labour, 
661 
Embryotomy,  478 

Emphysema,  subcutaneous,  in  labour,  663 
of  abdominal  walls,  following  rupture 
of  uterus,  665 


r,!H 


OPERATIVE  MIDYYIFEKY 


Enoephal le,  cause  ol  dystocia,  104 

Endometritis,  cause  of  abortion,  518 

cause  of  placenta  pnevia,  577 

cause  <>i   premature  separation  of  pla- 
centa, 595 
Enteropto8is.     See  Pendulous  abdomen 
Episiotomy,  649 
Ergotin.     See  Ergot 
Ergot  in  abortion  (threatened  .  526 

in  po8t-partum  luemorrhage,  610 

in  uterine  inertia,  1 1 
Estimation  of  age  of  child,  difficulty  of,  in 

induction  of  labour,  1 10 
Eucaine  in  spinal  anaesthesia,  B15 
Evisceration,  ".04 
Evolution,  spontaneous,  88 
Examination,  abdominal,  15 

bimanual,  in  estimating  relative  size  of 
pelvis  and  foetal  head,  187 

rectal,  25 

vaginal,     few     weeks     before    labour, 
importance  of,  22 
in  lection  from,  21 
limitating  number  of,  20 
Exostosis,  causing  injuries  to  foetal   head, 
067 

producing  pelvic  deformities,  169 
Expression  of  ovum  in  abortion,  527 

of  placenta  (Crede's  method),  513 
External    version    (see    Version,    external), 

325 
Extraction  of  after-coming  head,  69 

of  breech,  57 
Extra-uterine  pregnancy,  537 

abdominal  (primary),  547 

adipocerous  change  in  foetus,  565 

advanced,  564 

ampulla,  implantation  in,  538 

associated  with  intra -uterine,  576 

classification  of,  537 

clinical  features,  550 

decidua,  tubal,  538 
uterine,  549 

differential  diagnosis,  552,  559 

dysuria  in.  276,  558,  572 

hematocele  following,  571 

interstitial,  543 

isthmic,  542 

lithopii-dion  formation  in,  565 

ovarian,  545 

pain  in,  555 

pathological  anatomy  of,  537 

repeated,  576 

rupture  of,  539,  551,  555 

symptoms  of,  550 

terminations  of,  538 

treatment  of,  566 

tube  wall,  changes  in,  538 

vaginal  haemorrhage  in,  557 

varieties  of.  537 

Face  presentations,  causes  of  dystocia,  35 
causation  of,  35 

complicated  by  contracted  pelvis,  39 
conversion  of,  into  vertex,  39 


Pace  presentations,  craniotomy  in,  187 
diagnosis  of,  36 
forceps  in 
frequency  of,  37 
injuries  to  child,  87 
mento-postei  ior  position  of,  12 
prognosis,  87 
symphysiotomy  in,  li 
treatment  of,  88 
version  in     • 
facial  paralysis  following  forceps 

676 
Factors  influencing  labour,  3 
Faraboeufs    prebenseur-levier-mensurateur, 

372 
Fascia,  pelvic,  limiting  effusion  of  1 

209 
Fatty  degeneration  of  uterine  wall  ca  . 

rupture  ot  uterus,  618 
Fevers,  specific,  causes  of  abortion,  519 

induction  of  labour  in,  436 
Fibro  •  myomata     causing     dyst 

Myoma),  235 
Fillet  in  impacted  breech,  MJ 
Flat  non-rachitic  pelvis,  157 
rachitic  pelvis,  160 
diagnosis  of,  177 
factors  influencing  birth,  192 
features  of,  160 
forceps  in,  195,  363 
mechanism  of  labour  in.  104 
prognosis,  188 

treatment  (see  Contracted  pelvis  . 
189 
Foetus,  abdomen,  enlargement  of,  107 

abnormalities  of,  obstructing  labour,  '.'7 
ascites  of,  cause  of  dystocia,  109 
attitude  of,  in  utt  ro,  15 

in  face  presentation,  35 
bladder,  distension  of,  109 
calcification    of,    in    advanced     extra- 
uterine pregnancy,  565 
circulation    of,    disturbances    of, 

Foetus,  heart  sounds 
cystic  kidneys  of.  110 
death,  signs  of  impending,  4,  23,441.  689 
estimation  of  age  of,  difficulty  of,  443 
excessive  size,  97.  1 12 
fracture  of  bones  of.  in  uter         ' 
general  dropsy  of,  98 
habitual  death  of,  induction  of  labour 

for,  441 
head.     See  Head,  foetal 
heart -sounds,  auscultation,  importance 
of,  23 
in  prolonged  labour,  4,  682 
in  twin  pregnancy,  114 
hydrocephalus  of,  99 
injuries  to,  during  labour,  666 
length  of,  measurement  in  utero,  44:; 
malformations  of,  cause  of  dystocia.  97 
movements,  excessive,  before  death,    I, 

682 
mummification    of,    in    extra  -  uterine 
pregnancy.  565 


INDEX 


695 


Foetus,  over-development  of,   induction   of 

labour  for,  44 2 
position    of,    alterations    in    cause    of 

dystocia,  26 
pressure  marks  on,  668 
size  of,  in  contracted  pelvis,  192 
tumours  of  body  of,  cause  of  dystocia, 

106 
Fontanelle  presentations,  32,  33 
Foot,  bringing  down,  in  breech  eases,  52 
choice  of,  to  bring  down,  52,  320 
diagnosis  from  hand,  90 
Forceps,  333 

action  of,  339 

adjustable     axis  -  traction     forceps     of 

Milne  Murray,  337 
anteroposterior,  372 
application  of,  347 
as  dilator  of  cervix,  344 
axis-traction,  336 
Cameron's  forceps,  372 
cephalic  application  of,  347 
choice  of,  336 
compression,  amount  of,   exercised  by 

forceps,  310 
conditions  necessary  before  application 

of,  344 
facial  paralysis  following,  676 
foetal   mortality   in   contracted    pelvis, 

195,  366 
head  movable  above  brim,  345,  364 
high  in  cavity,  354 

condemnation  of,  with  head  mov- 
able, 363 
history  of  axis- traction,  333 
indications  for,  341 
in  after-coming  head,  69,  360 
in  breech,  impacted,  83,  362 
in  brow  presentations,  45,  360 
in  contracted  pelvis,  195,  363 
in  face  presentations,  43,  359 
in  flat  pelvis,  195,  363 
in  generally  contracted  pelvis,  195,  372 
in  mento-posterior  position  of  face,  360 
in  occipito-posterior  presentations,   32, 

357 
in  posterior  parietal  presentations,  165, 

195,  368 
in  prolapse  of  cord,  137 
in  protracted  second  stage  of  labour, 

12,  342 
limitations  in  contracted   pelvis,   195, 

338,  366 
low,  350 

mechanics  of  axis-traction,  333 
Mdne  Murray's  forceps,  337 
Neville's  forceps,  337 
operation,  ordinary,  349 
ovum,  527 

Pajot's  manoeuvre,  334 
pelvic  application  of,  348 
perineal     tears,    prevention     of,    with 

forceps,  353.  646 
position  of  patient,  346 
preparations  for  operation,  345 


Forceps,  prognosis  of,  in  contracted  pelvis, 

190,  195,  373 
Tarnier's,  333 

tr.ui ion,  amount  to  be  employed,  196, 
339,  390 

version  contrast. -.1,  193 

Walcher  position   in   forceps  delivery, 
346,  371 
Forces  concerned  in  labour,  3,  5 

dystocia  due  to  faults  in,  5 
Fornix,  rupture  of,  during  labour  (colpor- 
rhexis),  629 

rupture  in  manual  removal  of  ovum,  527 
Fractures  of  fcetal  bones  ui  utero,  667 

of  fcetal  skull  during  labour,  667 

of  pelvis,  170 
Fundus  incision  in  Cesarean  section,  411 
Funic  souffle  with  short  cord,  145 
Funis.     See  Umbilical  cord 

Generally    contracted    pelvis    (justo- minor 
pelvis),  155 
mechanism  of  labour  in,  33,  155 
prognosis    and    treatment.      See   Con- 
tracted pelvis 
Glycerine,  inducing  labour  by  injection  of, 

452 
Graves'  disease  in  pregnancy,  induction  of 

labour  for,  439 
Grossesse  extramembraneuse,  150 

Habit  of  abortion,  520 

Habitual  death  of  fcetus,  441,  519 

induction  of  labour  for,  441 
Htematocele,  pelvic,  571 

treatment  of,  573 
Hsematoma   of    broad   ligament,    in   extra- 
uterine pregnancy,  541,  567 
of  sterno-mastoid  muscle  of  new-born, 

672 
of  vagina  and  vulva,  209 
subperitoneal,  210,  598 
Hematosalpinx  (see  Mole,  tubal),  541 
Haemorrhage,    accidental    (see     Accidental 
haemorrhage),  594 
of  placenta  prsevia  (see  Placenta  previa), 

577 
in  abortion,  520 
intracranial  (fcetus),  673 
intraperitoneal   in   extra-uterine    preg- 
nancy, 539 
in  rupture  of  uterus,  635 
post-partum  (see  Post-partum  haemor- 
rhage), 607 
secondary  post-partum,  615 
transfusion  in,  614 

unavoidable  (see  Placenta  previa),  577 
vaginal,  in  extra-uterine  pregnancy,  557 
Hand  disinfection,  307 

fcetal,  diagnosis  of,  90-91 
Head,  after-coming.    See  After-coming  head 
consistency  of  influencing  labour,  187, 

192 
diameters,    alterations,    from   compres- 
sion, 193,  341 


696 


OPERATIVE  MIDWIFERY 


Read,  foetal  changes  in  shape  of,   in  brow 
presentations,  15 
in  face  presentations,  :;7 

in  oooipito  posterior  positi f  vertex, 

29 
injuries  to,  during  labour,  666 
measuring  fcBtal  bead  in  utero,  ivs 
size  influencing  labour,  '.'7,  192 
size  relative  to  maternal  pelvis,  impor- 
tance of  estimating,  187 
Heart,  diseases  maternal,  induction  of  labour 
for,  438 
foetal,  alterations  in  protracted  labour, 
4,  343.  682 
auscultation  of,  23 
face  presentation.  -i7 
in  twin  pregnancy,  24,  111 
situation  of  maximum  intensity  in- 
dicating  position  of  child,  24 
Hebotomy  (hebosteotomy),  398 
Hegar's  sign  of  pregnancy,  "244 
Herman's  method  of  symphysiotomy,  392 
Hermann's  forceps,  335 
Hernia  of  pregnant  uterus,  288 
High  forceps  (see  Forceps,  high),  354 
Hook,  blunt,  492 

use   of,    for   bringing   down    impacted 
breech,  81 
Hour-glass  contraction  of  uterus,  14 
Hydatidiform  mole,  532 
benign,  534 
destructive,  534 
malignant,  534 
pathology  of,  533 

relation  of,  to  chorion-epithelioma,  533 
rupture  of  uterus  from,  536,  618 
symptoms  of,  535 
treatment  of,  536 
Hydramnios,  induction  of  labour  for,  440 

malpresentations  resulting  from,  86 
Hydrocephalus,  cause  of  dystocia,  99 
cause  of  rupture  of  uterus,  102,  626 
craniotomy  in,  103,  479 
diagnosis  of,  100 
presentations  in,  100 
prognosis,  102 
spinal  tapping,  104 
treatment,  103 
Hydrorrhcea  gravidarum,  diagnosis  of,  from 
rupture  of  membranes,  149 
caused  by  grossesse  cxtramembraneusc, 
150 
Hymen,  atresia  of,  cause  of  dystocia,  207 
Hyperemesis     gravidarum,     accouchement 
force  in,  456 
induction  of  labour  in,  439 
vaginal  Ca-sarean  section  in,  475 
Hypertrophy  of  cervix,  cause  of  dystocia, 
201 
C'resarean  section  for,  201 
Hypsiloid  (dicephalous)  monster,  127 
Hysterectomy   for  accidental   haemorrhage, 
604 
for  carcinoma,  218 
for  myomata,  250 


Hysterectomy,  for  rupture  ol  uterus,  641 
supravaginal,  after    Cesarean   section, 

417 

total,  after  •  taeean  an  section,  128 
ii. il.  in  i  aroinoma  ol  oen  ix,  219 
in  accidental  hemorrhage,  <>')\ 
Hysb  Luse  ol  dystocia,  290 

Icterus  gravidarum,  induction  ol  labour  for, 

ill 
Incarceration  of  prolapsed  gravid  utei  u 

of  retroflexed  gravid  uterus,  270 
Inclination  of  pelvis,  vai  iations  ol 
Incomplete  abortion,  522 
Induction  of  abortion  (see  Abortion,  induc- 
tion ol),  458 

of  prematun-    labour    (see    Premature 
labour,  induction  of  ,  135 
Inertia  uteri  (see  Uterine  inertia  . 
Inevitable  abortion,  527 
Infant.     See  New-born  child 
Infantile  paralysis,  effect  upon  pelvis,  175 

pelvis.  155 
Infundibuliun  implantation  of  ovum  on,  ">42 
Injuries  to  birth  canal,  616 

following  forceps  delivery,  195 

to  child  in  "'<  ro,  667 

during  parturition,  667 
Insufflation  of  lungs  in  asphyxia    m 

torum,  684 
Internal  version,  318 
Interstitial  pregnancy,  543 
Intracranial  haemorrhage  (foetal),  673 
Intrauterine  douche.     See  Douche 
Inversion  of  uterus,  causes  of,  655 

hysterectomy  for,  660 

repositor  for,  661 

spontaneous  reposition,  660 

symptoms,  diagnosis,  and  prognosis,  658 

treatment.  659 
Ischio-pubiotomy,  402 
Isthmic,  pregnancy  in,  542 

Jardine's  decapitating  hook,  502 
.Jaundice  of  mother.  See  Icterus 
Johnson's  method  of  measuring  conjugata 

vera,  185 
Joint,  pubic,  anatomy  of,  381 
Justo-major  pelvis,  155 
Justo-minor  pelvis,  155 

Kerr,  method  of  estimating  relative  size  of 

fcetal  head  and  maternal  pelvis,  188 
Kidney,  changes  in,  induction  of  labour  for. 
See  Albuminuria 

cystic,  of  fo  lit\  cause  of  dystocia,  111 
Knee  presentation.    See  Breech  presentation 
Knots  of  umbilical  cord,  1 15 
Krause's  method  of  inducing  labour,  1 19 
Kyphotic  pelvis,  171 

symphysiotomy  in,  173 

Labium  majus,  oedema  of,  204 
Labour,  anaesthesia  during,  314 
asepsis  and  antisepsis,  307,  311 


INDEX 


(597 


Labour,  auxiliary  forces  of,  9 

complicated.     Sec  Dystocia 

death  during,  GUI 

dry,  148 

ergot  during,  11 

examination  in,  limiting  of,  21 

factors  influencing,  3 

Mat  pelvis,  164 

force  exerted,  7 

forces,  5 

generally  contracted  pelvis,  155 

haemorrhage  during.     See  Haemorrhage 

in  elderly  primiparae,  203 

obstructed.     See  Dystocia 

pains  of.     See  Forces 

precipitate,  7 

premature,  induction  of  (see  Induction 
of  labour),  435 

preparations  of  patient  for,  311 
of  room,  bed,  etc.,  303 

prolonged,   cause    for   interference,    12, 
342 

spinal  anaesthesia,  315 

third  stage,  management  of,  508 

uterine  contractions.     See  Forces 

vaginal  examination  during,  21 
Lambdoid  (syncephalous)  monster,  129 
Langhan's  layer  of  chorion  in  hydatidiform 
mole,  533 

in  chorion-epithelioma,  534 
Laparotomy  during  pregnancy,  safety  of,  227 

for  extra-uterine  pregnancy,  566 

for  nbro-myomata,  247 

for  ovarian  tumours,  227 

for  rupture  of  uterus,  641 

for  retroflexed  gravid  uterus,  283 

for  suppurative  conditions  in  pelvis,  261 

preparation  for,  304 
Lateral    curvature    of    spine    (see    Pelvis, 
scoliotic),  173 

displacement  of  gravid  uterus,  265 

simulating  extra-uterine  pregnancy,  563 

simulating  fibro-myoma,  245 

placenta  pnevia,  579 

position  of  patient  in  parturition  (see 
Sims'  position),  137 

disadvantage  in  high  forceps,  346,  347 
Lead-poisoning,  cause  of  abortion,  519 
Leucocytosis   in  diagnosis   of  appendicitis, 

263 
Leukaemia,  cause  for  induction  of  labour, 

438 
Levator  ani,  injuries  to,  during  labour,  645 
Life,  prospect  of,  for  foetus,  2,  404,  442,  457 
Limitations,  general  remarks  on,  limitations 

of  different  operative  procedures,  1 
Lithoptedion,  565 
Litzmann's  obliquity,  164 

contra- indication  to  forceps,  367,  368 
Liver,  acute  yellow  atrophy   of,   cause   for 

induction  of  labour,  441 
Lochiometra  (retention  of  lochia),  288 
Locked  twins,  116 

Loops   in   umbilical   cord.      See   Umbilical 
cord 


Lower  uterine  segment,  620 

injury  of,  in  vaginal  Cresarean  section, 

477 
rupture  of,  620 

Malformations  of  fetus  causing  dystocia,  '.'7 

of  uterus  and  vagina  causing  dystocia, 
294 
Manual  dilatation  of  cervix,  459 

removal  of  placenta,  508 
Masculine  pelvis,  156 

Mauriceau's  method  of  delivering  the  after- 
coming  head,  72 
Meconium,  escape  of,  sign  of  fetus  in  danger, 

4,  682 
Membranes,  adhesion  to  lower  part  of  uterus 
cause  of  dystocia,  151,  204 

bag  of,  resistance  to  bursting  force,  148 

fetal,  premature  rupture  of,  148 

retention  of,  514 

rupture  of,  method  of  inducing  labour, 
448 

delayed  rupture  of,  150 

premature  rupture,  148 
Meningocele  cause  of  dystocia,  104 
Menses,  persistence  of,  in  pregnancy,  297, 

521,  557 
Menstrual  molimen  during  pregnancy,  518 
Mercurial  poisoning,  cause  of  abortion,  519 
Metreurynter  in  accidental  haemorrhage,  603 

in  accouchement  force,  461 

in  induction  of  labour,  450 

in  placenta  praevia,  591 

in  prolapse  of  funis,  141 

in  rigidity  of  cervix,  203 

method  of  inserting,  462 

of  Champetier  de  Ribes,  462 

of  Pomeroy,  462 

rupture  of,  462 

rupture  of  uterus,  591 
Metritis,  cause  of  post-partum  haemorrhage, 
608 
rupture  of  uterus,  619 
Michaelis'  rhomboid  in  contracted  pelvis,  179 
Miscarriage.     See  Abortion 
Missed  abortion,  524 

labour  in  extra- uterine  pregnancy,  565 
Mole,  blood,  carneous,  fleshy,  tuberose,  524 

hydatidiform,  532 

tubal,  541 
Mollities  ossium  (see  Osteomalacic  pelvis),  167 
Monsters,  double,  cause  of  dystocia,  122 
Morning  sickness  in  extra-uterine  pregnancy, 

558 
Moulding  of  head,  importance  of,  366 
Movements,  foetal,  excessive,  sign  of  danger 

to  child,  4,  682 
Midler's  method  of  estimating  size  of  head 

and  pelvis,  188 
Multiple  pregnancy,  113 

complications,  117 

course  of  labour  in,  116 

diagnosis  of,  113 

management  of,  116 

position  of  each  child,  115 


698 


0PERAT1VK  MlhWIl'KKY 


Myoma  of  uterus,  Cesarean  section  in,  263 
complicating  labour  and  pregnancy, 
285 
puerperiam,  25 1 
diagnosis  of,  244 
effect  of,  -:;"' 
treatment,  217 
of  vagina,  208 
Myomectomy  during  pregnancy,  248 
Myxoma  chorti  (see  Hydatidiform  moli 

jele's  obliquity,  18  1 
\  a<  gele's  pelvis,  l~>7 
Natural  delivery,  variations  in,  1 
Neck,  tumours  of,  in  foetus  causing  dystocia, 

106 
Nephritis,  induction  of  labour  for.  4:37.  i  10 
New-born  child,  accidents  to  the,  666 

asphyxia  neonatorum,  678 

birth  paralysis,  »J72 

bones,  injuries  to,  667 

cephalo-bsematoma  of,  666 

cerebral  hemorrhage.  673 

convulsions,  67 ,r> 

Duchenne's  paralysis,  077 

facial  paralysis,  676 

head  of,  injuries  to,  666 

muscles,  injury  to,  672 

skull,  fractures  of,  667 
indentations  of,  668 
Nuchal  or  dorsal  displacement  of  arm,  48,  68 

Obliquely  contracted  pelvis,  156 
Obstructed  labour.     Sec  Dystocia 
Occipito-posterior    presentations,    diagnosis 
of,  26 
forceps  in,  357 
rectification  of,  30 
treatment  of,  28 
Gidema,  acute,  of  cervix,  203 
of  fcetus,  98 
of  labium,  204 
of  lungs,  cause  of  death,  663 
Oligo-hydramnios,  cause  of  amniotic  bands, 

142 
Operations.     See  Particular  operations 

limitations  of,  general  remarks  regard- 
ing. 1 
Os  externum,  backward  displacement  of,  205 

occlusion  of,  204 
Osteomalacia,  pelvis,  167 

deformities  resulting  from,  168 
ovariotomy  for,  169 
pathology  of,  168 
Ovarian  pregnancy,  545 

tumours,  Cesarean  section  in,  229 
complicating  labour  and  pregnancy,  222 
the  puerperium,  233 
Ovariotomy  during  labour,  229 
pregnancy,  227 
for  osteomalacia,  169 
Ovum,  Fiith  tubal,  538 

site  of.  in  ectopic  pregnancy,  537 
trophoblast  of,   in   ectopic   pregnancy, 
540 


Oxytocic-,  in  criminal  abortion, 
lor  bringing  on  labour,  448 
lor  uterine  inertia,  1 1 

Pajot's  manoeuvre,      ; 
Palpation,  abdominal  importance  1 

breech  presentations,  50 

brow  presentations,  14 

contraction  ring  in  threatened  rupture 
of  titerus,  63 1 

face  presentation 

foetal  heart-beat  in  (ace  presentations,  8? 

occiput,  indicating  positii 

occipito-posterior  position 
placenta  in  placenta  previ  1 
position  an<(  attitude,  diagnosis  of,  by, 
18 

round  ligaments  in  diagnosis  < 
tion  of  placenta,   115 

transverse  presentations,  90 

twins,  118 
Paralysis,  birth  (Duchenne's),  877 

facial,  following  forceps,  676 

obstetrical  (Duchenne's  paralysis 
Parturition.     See  Labour 
Partus  conduplicato  corpore,  90 
PawHkgrip,  18 
Pelvic  abscess,  complicating  labour,  260 

lluor,  importance  of  preserving,  646 
Pelvigraph,  181 
Pelvimeters,  forms  of,  180 
Pelvimetry,  by  use  of  X  rays.    See  Appendix 
and  181 

external,  178 

internal,  180 
Pelvis,  assimilation,  159 

axis,     variations    of,    Milne    Murray's 
forceps  for,  337 

classification  of  deformities,  154 

contracted.     See  Contracted  pelvis 

coxalgic,  175 

deformities,  classification  of,  154 
etiology  of,  154 
frequency  of,  153 

development,    arrestment  of,    cause   of 
deformity,  154 

diameters,  alteration  of,  in  tlat  pelvis, 
161 

dislocation  of  femora,  176 

double  Xaegele  (see  Roberts),  158 

dwarf,  156 

etiology  of  deformities,  ]  5  I 

exostosis  of,  169 

figure  of  eight,  162 

Hat  non-rachitic,  157 

fiat  rachitic,  160 

fractures  of,  170 

funnel-shaped,  156 

generally  contracted,  155 

rachitic,  160 

enlarged,  155 

infantile,  156 

paralysis,  cause  of  deformity,  175 

joints  of,   injury  of,   after  symphysio- 
tomy, 394 


INDEX 


099 


Pelvis,  justo-major,  155 
justo-minor,  155 
kyphoscoliotic,  173 
kyphotic,  171 

masculine,  156 

measurements,  alterations   in    contrac- 
tion, 178 
movements  of,  in  connexion  with  sym- 
physiotomy, 375 
NTaegele's,  157 

obliquely  contracted  (Xaegele),  157 
obtecta,  174 

ossification   of,  faults  of,  cause  of  de- 
formity, 161 
osteomalacic,  167 
outlet  of,  measurement  of,  179 
pseudo- osteomalacic,    pseudo -malacos- 

teon,  167 
reniform,  162 
rachitic,  160 
Roberts',  15S 

rostrate  (see  Osteomalacia),  168 
scolio-rachitic,  163 
scoliotic,  173 
spinosa,  169 
split,  159 

spondylolisthetic,  174 
transversely  contracted,  158 
trifoliate  (see  Osteomalacia),  168 
tumours  of,  169 
Pendulous  abdomen,  cause  of  dystocia,  288 
malposition  of  foetus,  86 
rupture  of  uterus,  629 
Perforators,  cranial,  483,  484 
Perineum,  lacerations  of,  645 
central,  208 
prevention  of,  646 
repair  of,  650 
rigidity  of,  207 
Pernicious  anemia,  cause  for  induction  of 
labour,  438 
vomiting    of    pregnancy    (see    Hyper- 
emesis  gravidarum),  439 
Pessary  in  treatment  of  retroflexed  gravid 

uterus,  279 
Miantom  tumour  of  uterus,  244 
Phlebitis  following  haemorrhage,  615 
'lacenta,  abnormalities  of,  148 
adherent,  508 
battledore,  146 
bipartita,  148 

circular  sinus,  rupture  of,  148,  581 
diagnosis  of  position  by  palpation,  583 
expression  of,  by  Crede's  method,  513 
in  extra-uterine  pregnancy,  568 
in  multiple  pregnancy,  116,  146 
manual  removal  of,  509 
mechanism  of,  separation  of,  511 
•  edema  of,  148 
previa,  577 

accouchement  force  in,  457,  592 
Cesarean  section  in,  407,  593 
central  and  complete,  579 
clinical  features,  581 
developed  from  decidua  reflexa,  579 


Placenta  previa,  diagnosis  of,  683 
etiology  of,  577 
frequency  of,  579 
induction  of  labour  for,  586 

lateral,  579 
marginal.  579 
metreurynter  in,  591 
plugging  in.  586 
prognosis  of,  584 
symptoms  of,  581 
treatment  of,  585 
varieties,  579 
version  in,  588 
premature  separation  of  (see  Accidental 

hemorrhage  from  short  cord),  143 
prolapse  of,  577 
removal  of,  513 

retention  of,  cause  of  haemorrhage,  610 
site  of,  as  shown  by  Cesarean  sections, 

412 
succenturiata,  148,  516 
velamentous,  146 
vessels  of,  abnormalities  of,  146 
Placental  forceps,  528 

polypus,  521 
Plugging.     See  Tampon 
Plural  pregnancy.     See  Multiple  pregnancy 
Podalic  version,  318 

dangers  in  impacted  shoulder,  96,  323 
foot  to  seize,  320 
position  of  patient,  318 
technique  of,  318 
Pomeroy's  metreurynter,  462 
Porro's  operation,  417 

Position  of  foetus,  diagnosis  by  palpation,  17 
Post-mortem  Cesarean  section,  433 
Post-partum  hemorrhage,  607 
diagnosis  of,  608 
etiology  of,  607,  608 
primary,  607 
secondary,  615 
treatment  of,  609 
Postural  treatment  of  malposition,  94,  329 
Prague  method  of  delivering  after-coming 

head,  78 
Precipitate  labour,  7 
Pregnancy,  abdominal,  primary.  547 

accidents  during.     See  Abortion,  Acci- 
dental    haemorrhage,      Rupture     of 
uterus 
examination,   preliminary,  during,  23, 

177 
extra-uterine  (see   Extrauterine   preg- 
nancy), 537 
multiple  (see  Multiple  pregnancy),  113 
ovarian,  545 

protracted,  danger  to  child  from,  152. 
441 
induction  of  labour  for,  442 
signs  of,  152 
rudimentary  horn,  296,  574 
rupture  of  uterus  during,  616 
surgical   operations   during,   199,    213, 

221,  234]  256,  261 
tubal.     See  Extra-uterine  pregnancy 


-<>(> 


OPERATIVE  MIDWIFERY 


I ' t  < •  I u ■  1 1 s.  u  r -  K- v i i- r -  r 1 1 < •  1 1 n 1 1 1  .i i  <  1 1 1  of  Faraboeuf, 

372 
Premature  labour,  indications  for  Lndui 

for  carcinoma  oi  cen  i\.  2]  3 

fur  ohorea,  139 

foi  contracted  pelvis,  1 12 
foetal  prognosis  in,  i  IS 
indications  for,  142 
Limitations,  1 16 
maternal  prognosis,  I  12 
methods,  4 18 

for  excessive  size  of  child,  1 12 

fur  habitual  death  of  fotus,  441 

for  heart  disease,  438 

for  hydramnios,  1 10 

for  hyperemesis  gravidarum,  439 

for  icterus  gravidarum,  441 

for  nephritis,  437,  438 

for  pernicious  ana-niia,   13.* 

for  placenta  prsevia,  586 

for  protraction  of  pregnancy,  441 

methods  of,  448 
Premature  rupture  of  membranes,  148 

separation   of  placenta  (see  Accidental 
haemorrhage),  594 
Preparations  for  operations  (patient,  accou- 
cheur, etc.),  303 
Presentation  :  breech,  knee,  foot,  50 

brow,  43 

definition  of,  15 

diagnosis  of,  by  palpation,  15 

ear,  diagnosis  of  position  from,  23 

face,  35 

fontanelle,  anterior  and  posterior,  32,  33 

funic,  132 

occipito-posterior,  26 

oblique,  shoulder,  transverse,  86 

parietal,  anterior  and  posterior,  33,  164 
Frolapse  of  gravid  uterus,  289 

of  placenta,  577 

of  umbilical  cord,  132 
Promontory,  false,  163 

injury  to,  in  craniotomy,  486 
Protracted  labour,  forceps  in,  342 

pregnancy,  induction  of  labour,  441 
Pseudo-osteomalacic  pelvis,  167 
Pubiotomy,  398 
Puerperium,  appendicitis,  263 

myomatous  tumours  in,  254 

ovarian  tumours  in,  233 

salpingitis,  261 
Pulmonary  embolism,  661 

Quinine  as  an  oxytocic,  11 

Rachitic  pelvis,  160 
diagnosis  of,  177 
mode  of  production  of  pelvic  deformity 

in,  160 
treatment  of  labour  in,  1S9 
varieties  of,  160 
Rectum,   carcinoma  of,   complicating  preg- 
nancy and  labour,  257 
simple  tumours  of,  257 


Repositor  for  inverted  uterus,  661 

foi  prolapsed  umbilical  cord,  1 10 
Reposition  ol   prolapsed  arm  in  tram 
presentations,  S23 
funis,  137 

limbs  in  head  presentation 
Respiration,  artificial,  ol  child,  682 
R<  tained  Lochia,  28  - 
membranes,  •".  1 1 
placenta,  508 

removal  of,  "'1 1 
Retinil  is.  albuminuric,  438 
Retraction  ring.     See  Bandl'e  ring 
Retroflexion,  cause  of  abortion,  518 
of  bicornuate  uterus,  299 
of  gravid  uterus,  265 
diagnosis  of,  275 

differential,  from  extra-uterine 

preguancy,  -7  7         J 

featun-s  and  progress,  270 
laparotomy  for,  283 
treatment.  278 
varieties  of,  268 
Retroplacental  luematoina,  511 
Rhomboid  ofMichaelis,  179 
Rigidity  of  cervix,  201 

treatment  of,  203 
varieties  of,  201 
of  perineum,  207,  646 
Roberts'  pelvis,  158 
Roentgen  ray  in  determining  size  of  pelvis. 

See  Appendix 
Rotation  with    forceps  in   mento-posterior 
positions,  43,  360 
in  oceipito. posterior  positions,  32, 
357 
Round    ligaments,    indicating    position    of 

placenta,  415 
Rubber  gloves,  use  of,  310 
Rubber   instruments   and   gloves,   steriliza- 
tion of,  305 
Rudimentary  horn,  pregnancy  in,  295,  574 
Rupture  of  cervix,  643 
of  perineum,  645 
of  symphysis  pubis,  654 
of  tube  in  extra-uterine  pregnancy,  539 
of  umbilical  cord,  143 
of  uterus,  616 

diagnosis  of,  629 
during  pregnancy,  616 

etiology  of,  617 
early  in  labour,  627 
in  contracted  pelvis,  622 
in  infantile  uterus,  617 
in  hydatidiform  mole,  534 
in  hydrocephalus,  626 
in    neglected    transverse    presenta- 
tions, 623 
in  protracted  labour,  619 
in  pregnancy  in  bicornuate  uterus, 

301,  617 
in  removing  placenta,  626 
in  scar  of  Cesarean  section  wound, 

616 
plugging  in,  640,  643 


INDEX 


701 


Rupture  of  uterus,  prognosis,  637 
prophylaxis,  lilis 

repeated,  617 

spontaneous,  617,  627 
symptoms  of,  629 
threatened  rupture,  633 
treatment  of,  638 
varieties  of,  628 

Sacculation  of  uterus,  269 
Sacro-iliac  synchondrosis,  injury  in  symphy- 
siotomy, 394 
Sacrum,  tumour  of  foetal,  cause  of  dystocia, 

112 
Saline  transfusion  (see  Transfusion),  614 
Salpingitis,    diagnosis    from     extra-uterine 
pregnancy,  560 
in  puerperium,  261 
Sehafer's  pelotte,  7 
Schatz'a  tokodynamometer,  6 
School's  method  of  inducing  labour,  448 
Schultze's  method  of  separation  and  extru- 
sion of  placenta,  511 
method  of  rcsussitation,  684 
Scolio-rachitic  pelvis,  163 
Scoliotic  pelvis,  173 
Secondary  post-partum  haemorrhage,  615 

uterine  inertia,  9,  608 
Septum,  vaginal,  cause  of  dystocia,  298 
Shoulder  presentation   (see  Transverse  pre- 
sentation), 86 
diagnosis  of,  90 
large  shoulder  girdle,  cause  of  dystocia, 

106 
cause  of  rupture  of  perineum,  649 
Simpson's  basilyst,  494 
cephalotribe,  493 
forceps,  336 
perforator,  483,  4S4 
Sims'  position,  137 

advantage  in  impacted  breech,  84 
in  difficult  version,  319 
in  replacing  umbilical  cord,  137 
Skull,  ftetal,  injuries  (see  jSTew-born  child), 

666 
Skutsch's  pelvimeter,  182 
Srnellie's  scissors  perforator,  483 
Souffle,  funic,  23,  145 

uterine,  23 
Sphincter  ani,  laceration  of,  645 
repair  of,  653 
vaginae,  importance  of  preserving,  650 
Spinal  anaesthesia,  315 
Spinal  tapping  in  hydrocephalus,  104 
Split  pelvis,  159 
Spondylolisthetic  pelvis,  174 
Spondylotomy,  505 
Sponges,  preparation  of,  305 
Spontaneous  delivery  in  contracted  pelvis, 
191 
evolution,  88 

rupture  of  uterus,  617,  627 
version,  88 
Spurious  labour  in  extra-uterine  pregnancy, 
565 


Sterilization  of  hands,  instruments,  etc.,  -;'>l 

of  patient  after  Cresarean  Bection,  127 
Sterno-mastoid,  baematoma  of,  in  new-born, 

672 
Streptococcus  in  vagina  of  pregnant,  312 
Stovaine  for  spinal  anaesthesia,  315 
Subinvolution  of  uterus  from  retention  of 

membranes,  516 
Succenturiate  placenta,  148,  516 
Sudden  death  during  labour,  661 
Suppurative  conditions  in  pelvis  and  abdo- 
men, complicating  pregnancy  and  labour, 
260 
Sutures,  method  of  sterilizing,  306 
Symphysiotomy,  after-treatment,  390 

anatomy  of  parts  concerned  in,  381 

forceps   and  relative  position  of,   193, 
367,  378,  379 

history  of,  374 

Cesarean  section  contrasted,  379,  404 

dangers  and  injuries  resulting  from,  394 

drainage  after,  390 

delivery  after,  388 

enlargement  of  pelvis,  376 
permanent,  397 

general  considerations  regarding,  375 

in  face  and  brow  presentations,  46,  375 

in  kyphotic  pelvis,  173 

indications  for,  377 

pelvic  measurements,  effect  on,  375 

prognosis  of,  393 

puliiotomy  contrasted,  400 

repeated,  396 

results,  391 

subcutaneous,  391 

technique  of,  384 
Symphysis  pubis,  rupture  of,  in  labour,  654 
Syncephalous  monster,  129 
Synchondrosis,    sacro  iliac,     injury    to,    by 

symphysiotomy,  394 
Synclitism,  164 
Syphilis,  cause  of  aboition,  518 

Tampon  in  abortion,  528 

accidentil  haemorrhage,  601 

in  placenta  pi\evia,  586 

in  post-partum  hemorrhage,  611 

in  rupture  of  uterus,  640,  643 
Tamier's  basiotribe,  493 

ecarteur  uterin,  466 

forceps,  333 
Tetanic  contraction  of  uterus,  13 

prior  to  rupture,  633 
Third  stage  of  labour,  physiology  of,  511 
Thoracopagous  monster,  123 
Threatened  abortion,  521,  526 
Thrombosis  after  haemorrhage,  615 
Thyroid,  tumours  of,  cause  of  dystocia,  107 
Tokodynamometer,  6 

Transfusion   of  salt   solution  in  eclampsia, 
407,  457 

for  haemorrhage,  613 

intracellular,  614 

rectal,  til  1 

venous,  61-1 


702 


OPERATIVE  MIDWIFE m 


Transverse  presentations,  dystocia  in,  86 
oephalio  version  in,  94 
course  ol  labour  in,  s7 
decapitation  in,  96,  ! 
diagnosis  of,  '•ii| 
impacted,  96 
poualic  version  in,  95 
rupture  of  uterus  in,  <'■- 
treatment  of,  98 

Transversely itraeted  pelvis,  158 

Trephining  akull   for  intracranial   hemor- 
rhage, indentations  of  skull,  671,  072,  673, 
675 
Tubal  abortion,  538 

pregnancy    (sec     Extra -uterine     preg- 
nancy), 537 
Tuberose  mole,  52  1 

Tumours,  abdominal,  diagnosis  of,  in  preg- 
nancy, '224,  244 
-  of  bladder,  complicating  pregnancy  and 

labour,  256 
of  fcetus,  98,  104,  106,  107,  109,  110 
of  ovary,  222 
of  pelvis,  169 
of  rectum,  257 
of  uterus,  235 
of  vagina,  20S 
Turning  (see  Version),  316 
Twin  pregnancy  (see  Multiple  pregnancy), 

113 
Twins,  locked,  117 

Umbilical  cord,  causing  dystocia,  132 
abnormalities  of,  145 
coils  of,  about  neck  and  body  of  child, 143 
knots  of,  146 
long,  145 

loops  of,  about  neck  and  body,  1 13 
marginal  insertion  of,  146 
prolapse  of,  132 
reposition  of,  137,  139 
rupture  of,  143 
short,  cause  of  dystocia,  141,  657 

treatment  of,  145 
shortness    of,    cause    of    inversion    of 

uterus,  657 
souffle  in  short  cord,  145 
strangulation  of,  bv  amniotic  adhesions, 

143 
torsion  of,  145 
variations  in  insertion  of,  146 

in  length  of,  145 
velamentous,  insertion  of,  146 
Unavoidable     haemorrhage     (see     Placenta 

previa),  577 
Urine.     See  Dysuria 
Uterine  inertia,  8 

cause  of  post-partum  haemorrhage, 

608 
diagnosis  of,  10 
reason  for  interfering,  12,  342 
treatment  of,  10 
souffle,  auscultation  of,  23 
Uterus,  anteflexion  of,  cause  of  dystocia, 
287.  290 


Uterus,  atony    o  if  posl   partum 

Demon  h 
bioornis,  297,  800 
bipartite,  297 
carcinoma  of,  21 1 
cordiformis,  297 
causing  transverse  presentation,  - 

resembling  rapture  of  uterus,  I 
contractions,  irregular,  9,  1 1 
displacements  of,  265 
double  complication-  of.  2'.'- 

diagnosis  of,  300 

rupture  of,  300 

treat  ment,  802 

varieties,  296 

with  rudimentary  horn,  294,  57  l 
didelphys,  297,  298 
hour-glass  contractions  of,  14 
incarceration  of  retroflexed,  270 
inertia,  cause  of  dystocia,  3,  8 
inversion  of,  655 

lateral  displacements  of,  215.  265, 
malformations  of,  294 
myoma  of,  234 
perforation  of,  530,  536 
prolapse  of,  289 
retroflexion  of,  265 
retroversion  of,  208 
rupture  of,  616 
sacculation  of,  269,  279 
septus,  296,  298 
subseptus,  296 

tumours  of,  complicating  pregnancy, 235 
unicornis,  296 

Vagina,  atresia  of,  206 

bands  and  cicatrices,  206 

diaphragm  in,  207 

double,  298 

fornix,  laceration  of,  527,  62!) 

hematoma  of,  209 

laceration  of,  during  labour,  652 

malformation  of,  298 

septa  in,  207,  298 

sphincter,  preservation  of,  650 

stenosis  of,  206 

tumours  of,  208 
Vaginal  Cesarean  section,  470 

douche,  312 

drainage,  573 

examination  during  pregnaucy,  limita- 
tion of,  21 

fixation,  cause  of  dystocia,  290 

hysterectomy  for  carcinoma  of  cervix, 
219 
in  accidental  haemorrhage,  604 

septum,  cause  of  dystocia,  207.  2  18 
'  Vagitus  uterinus,'  682 
Velamentous  insertion  of  cord,  146 
Venous  transfusion,  614 
Veutro-nxation,  cause  of  dystocia,  292 
Version,  316 

after  symphysiotomy,  389 

bipolar.  329 

in  plaeenti  previa,  588 


INDEX 


703 


Version,  Braxton  Hicks  (see  Bipolar  version), 
329 

cephalic,  85,  316,  326 

dangers  of,  in  impacted  shoulder  presen- 
tation, 96,  325,  501 

external,  325 

history  of,  316 

indications  for,  317 

in    breech    presentation   during    preg- 
nancy, 85 

in  brow  presentations,  45 

in  contracted  pelvis,  193 

in  face  presentation,  38 

in  posterior  parietal  presentation,  193 

in  transverse  presentations,  93 
indications  for,  317 

podalic  (see  Podalic  version),  318 

spontaneous,  88 
Vertex     presentations,     abnormalities     of, 

c  uising  dystocia,  26 
Vesical  calculus  complicating  labour,  256 
Vesicular  mole,  532 


Vestibular  bulbs,  injury  to,  in  symyliysio- 

tomy,  383 
Vestibule,  laceration  of,  384,  608 
Vomiting,    excessive,    of    pregnancy.      See 

Eyperemesis  gravidarum 
Vulva,  abscess  of  Bartholin's  gland,  209,  260 

hematoma  of,  20'.' 

injuries  of,  during  labour,  607,  645 

oidema  of,  204 

tumours  of,  208 

Walcher's  position,  156,  199,  370 
association  with  forceps,  371 
symphysiotomy,  389 

X  rays  in  determining  size  of  pelvis.     See 
Appendix 

Zweifel's  pelvimeter,  184 

symphysiotomy,  method  of  performing, 
38S,  393 


THE    END 


BAILLIERE,    TINDALL    AND    COX,    8,    HENRIETTA    STREET,    COVENT  GARDEN 


DATE  DUE 

*,*»" — 1 

ti.bR  'i 

II 

m 

X*.r%\  v 

A  1007 

j.v  -  5  urn 

APR 

I  **  {IV 

zhi       J  tf 

.- 

:  ■■    r' 

^# 

Demco.  Inc.  38-293 


COLUMBIA  UNIVERSITY  LIBRARIES 


0043058094 


Kerr 

Operative  midwifery. 


RG725 

Kk6 

1911 


